P1722 Post myocardial infarction pericarditis or subacute left ventricular free wall rupture after acute myocardial infarction- a role of multimodality imaging
Authors: Ledakowicz-Polak A , Kacprzak M , Szymczyk K , Zielinska M 
Published: January 2020

Abstract

Introduction
Moderate to severe pericardial effusion (PE) in patients with acute myocardial infarction (AMI) can be associated with a broad spectrum of etiologies like left ventricular free wall rupture (LVFWR) or post- myocardial infarction pericarditis (PMIP).
We present a case of successful medical treatment of patient with subacute LVFWR after AMI, initially managed as PMIP.

Case Presentation
A 60- year- old man with a history of hypertension was admitted with persisting chest pain for 72 hours, with diagnosis of ST- segment elevation AMI of inferior wall. Patient underwent a percutaneous coronary intervention (PCI) of the right coronary artery as the AMI culprit vessel. Two days after PCI patient experienced progressive sharp chest pain, dyspnea and low- grade fever. Clinical evaluation revealed elevated inflammatory markers and pericardial rub. Transthoracic echocardiography (TTE) showed PE up to 10 mm. Patient has been diagnosed and treated as PMIP. During further observation patient had TTE performed repeatedly. Four days after PCI TTE revealed PE of 20 mm thickness and suspicion of subacute LVFWR of the lateral wall. Cardiac magnetic resonance (CMR) confirmed the diagnosis. Due to hemodynamic stability, the patient received only medical treatment. During further hospitalization TTE was performed every day. On fifteenth day both TTE and CMR didn’t reveal any rupture. Moreover patient was readmitted 6 weeks after initial hospitalization and TTE again did not show the LVFWR.

Discussion
Post AMI patients with PE who fulfill pericarditits diagnostic criteria should be managed as having PMIP. Nevertheless LVFWR should also be considered as frequent diagnosis of PE. Echocardiography is crucial in the prompt diagnosis of PE. In our presented case, the TTE did not show initially the LVFWR, only repeatedly performed investigation showed the increasing amount of PE and raised suspicion of subacute LVFWR, which was confirmed in CMR.
CMR has become a tool providing accurate diagnosis and visualization of the localization of rupture. Moreover CMR imaging can show LVFWR revealing whether the hematoma is circumscribed to the myocardium or communicates with ventricular cavity or the pericardial sac.
LVFWR is a catastrophic complication accounting for a significant proportion of in-patient deaths. It is accepted that emergent surgical repair is the cornerstone treatment for patients with LVFWR. However, similarly to ours, some cases with fairly good survival rates following isolated medical treatment have been reported. This clinical situation stands somewhere between the insidious free rupture into the pericardial cavity and the formation of the pseudoaneurysm.

Conclusions
Our presentation illustrates the usefulness of repeated multimodality imaging for the diagnosis and follow up of patients with PE after AMI. Our case also underscores the value of a conservative approach as a valid alternative to surgery in some patients with subacute LVFWR.