key: cord-0768087-4joy2kbg
authors: Allende, Norberto Gustavo; Santos, Ramiro; Sokn, Fernando Jose; Merino, Sabrina Andrea; Accastello, Gerardo Maximiliano; Medina, Juan Carlos; Isquierdo, Ignacio Nicolas; Rapallo, Carlos Alberto
title: Unusual presentations of cardiac rupture during COVID‐19 pandemic
date: 2021-02-18
journal: Echocardiography
DOI: 10.1111/echo.15006
sha: 106966874abfd5a92478372b281f839c99f67241
doc_id: 768087
cord_uid: 4joy2kbg

The Covid‐19 pandemia has many other undesirable consequences apart of virus infection. Less people is hospitalized due to acute coronary syndrome and the delay to seek medical attention has increased. Patients with ST segment elevation myocardial infarction arrive at the hospital too late to be timely treated and we have recently seen mechanical complications that were more frequent in the past decades before the use of reperfusion strategies. In this report we describe the presentation, evolution and detailed imaging evaluation of two patients with unusual presentations of cardiac rupture: left ventricular pseudoaneurysm and left ventricular intramyocardial dissecting hematoma.

In the early days while our country was facing the COVID-19 pandemic, the government established an extensive quarantine to slow down the growing curve of this infectious disease. Meanwhile, we were observing a lower incidence of people being hospitalized due to acute coronary syndrome together with an increased delay in these patients seeking medical attention. This scenario was already described by the first countries struck by the coronavirus outbreak and is perhaps one of the reasons for the significant increase in cardiac arrest taking place outside of hospital enviroments. 1, 2 Many patients with ST segment elevation myocardial infarction arrive at the hospital too late to be timely treated, and we have recently seen mechanical complications that were more frequent in the past decades before the use of reperfusion strategies.

In this report we describe the presentation, evolution and detailed imaging evaluation of two patients with unusual presentations of cardiac rupture.

A 70-year-old female patient with a history of hypertension and hypothyroidism was attended in the emergency department because of palpitations and dyspnea. Physical examination showed inspiratory crackles over the inferior half of the lung fields, jugular venous distention, a 3/6 systolic murmur, and mild orthopnea. Blood pressure was 140/80, heart rate 120 beats/min and respiratory rate 25 breaths/minute. Admission ECG revealed rapid atrial fibrillation with QS complex and negative T waves in anterior and inferior leads that spontaneously converted to sinus rhythm soon after arrival ( Figure 1A ). Laboratory tests were unremarkable, notably troponin and creatine phosphokinase were normal, and therefore, a recent anterior-inferior (apical) myocardial infarction was diagnosed.

When the patient was asked about any symptoms in the previous weeks, she said she had felt moderate intensity pain in her left arm followed by two syncopal episodes 45 days previous; however, she did not request medical attention due to fear of becoming infected with COVID-19. The following day an echocardiogram revealed a 

A 61-year-old male patient with a history of diabetes, hypertension, and cigarette smoking was brought to the emergency room complaining of substernal chest pain associated with class IV dyspnea lasting more than 48hs. He had experienced frequent anginal symptoms for three weeks before seeking medical attention but had decided to stay home to avoid contact with COVID-19infected patients. At arrival, he had cold extremities, tachypnea, tachycardia, and his blood pressure was 90/50. The ECG depicted prominent Q waves in anterior and inferior leads with 2 mm re- Echocardiography is the usual imaging method to establish the diagnosis because of its widespread availability and excellent imaging quality. The usual finding is an anechogenic cavity of variable size adjacent to the myocardial structures communicated to the LV cavity by a smaller neck with systo-diastolic bidirectional flow. A useful criterion for differential diagnosis with a true aneurysm is the ratio of the orifice width to the maximal parallel internal diameter of the neo-cavity of less than 0.5 (it was 0.28 in our case). 3 Surgical treatment is recommended when diagnosis is established during the first month of myocardial infarction because risk of rupture is unpredictable. Nevertheless, some chronic cases are incidentally discovered and may be followed and treated conservatively. 4 The second case described in this report represents another unusual presentation of myocardial rupture. Intramyocardial dissecting hematoma has been already described a long time ago in necropsy specimens but with improvements in imaging methods it can be readily displayed in vivo. Characteristic pathologic features are massive infiltration of blood into and through the myocardial wall dissecting between the muscle bundles, sometimes resulting in large channels and lakes. 5 The mechanism might be related to hypoxia-induced endothelial disruption of small intramyocardial vessels with hemorrhage and swelling of the infarcted area. Incomplete and delayed reperfusion may predispose to this complication, as previous reports described a higher angina-balloon time, low prevalence of TIMI 3 flow, and a poorer myocardial blush in this group of patients. 6 Optimal treatment in this scenario is still under debate, but short-term prognosis is usually good when only apical segments are involved. 7, 8 Echocardiography and CMR can precisely delineate the hematoma, and serial follow-up testing might demonstrate the reduction in its volume across days or weeks as in our case 2.

In conclusion, we present two different morphological expressions of cardiac rupture in myocardial infarction. Since transmural necrosis is the usual pathologic substrate favoring this complication, the delay in performing angiography and the failure to open the infarct-related artery might have had a key role in both of our cases.

The fear of going out to seek medical attention may result in a collateral damage of the COVID-19 outbreak precluding a timely diagnosis and treatment. Nowadays, a proper diagnostic approach of these rare complications can be made with noninvasive imaging methods.

The data that support the findings of this study are available in the supplementary material of this article. 

Reduced rate of hospital admissions for ACS during Covid-19 outbreak in Northern Italy

Reduction in STsegment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic

Differentiation of left ventricular pseudoaneurysm from true aneurysm with two-dimensional echocardiography

Left ventricular pseudoaneurysm

Clinical and pathologic features of postinfarction cardiac rupture

Intramyocardial dissecting hematoma in anterior wall ST elevation myocardial infarction: impact on left ventricular remodeling and prognosis

Left ventricular intramyocardial dissection after myocardial infarction

Dissecting intramyocardial hematoma: clinical presentation, pathophysiology, outcomes and delineation by echocardiography