Download Relation of left ventricular free wall rupture and/or

Relation of left ventricular free wall rupture and/or aneurysm
with acute myocardial infarction in patients with aortic
stenosis
Irtiza N. Sheikh, BS, and William C. Roberts, MD
This minireview describes 6 previously reported patients
with left ventricular free wall rupture and/or aneurysm
complicating acute myocardial infarction (AMI) in patients with aortic stenosis. The findings suggest that left
ventricular rupture and/or aneurysm is more frequent in
patients with AMI associated with aortic stenosis than
in patients with AMI unassociated with aortic stenosis,
presumably because of retained elevation of the left
ventricular peak systolic pressure after the appearance
of the AMI.
I
n 1983, one of us (WCR) reported a patient
with severe aortic stenosis (AS) and a healed
left ventricular (LV) apical aneurysm (1). The
authors speculated that LV aneurysm and LV
free wall rupture would be more frequent in
patients with acute myocardial infarction (AMI)
associated with severe AS than in patients with
AMI without AS. Herein, we summarize findings
in 5 subsequently reported patients with LV rupture and/or aneurysm with AMI associated with
severe AS.
Table 1. Reported cases of acute myocardial infarction in patients with aortic
valve stenosis with left ventricular free wall rupture or aneurysm
Reported cases: First author, year of publication
1
Roberts
1983
2
Duke
1984
3
Connary
1994
4
Kadri
1994
5
Ikeda
2002
6
Tanaka
2006
1. Age (years) at AMI
62
57
62
58
69
74
2. Sex
M
M
F
F
F
F
3. LV free wall rupture
0
+
+*
+
+
+
4. LV aneurysm
+
0
+
0
+
0
Variable
5. Days from AMI onset to rupture
–
6
?30
10
20
2
6. Previous hypertension (history)
+
0
–
+
–
+
7. ECG location of the infarct
–
Ant
Ant
Ant
–
Ant
8. Apical location of the infarct
+
+
0*
+
+
–
9. LV-SA psg (mm Hg)
–
–
50
105
70†
177†
10. Aortic valve area (cm2)
–
–
0.4
–
0.7†
0.3†
–
110/70
100/60
150/90
–
116/85
630
610
–
–
–
–
11. Systemic artery (s/d) (mm Hg)
12. Heart weight (g)
*False left ventricular aneurysm.
†By echocardiogram.
AMI indicates acute myocardial infarction; Ant, anterior; ECG, electrocardiographic; LV, left ventricular; psg,
peak systolic gradient; SA, systemic artery; s/d, peak systole/end diastole.
METHODS
An initial PubMed search was conducted to
locate publications of “cardiac rupture or aneurysm in patients with acute myocardial infarction complicated
by aortic stenosis.” A second search was made for publications
of “myocardial infarction in patients with aortic stenosis.”
RESULTS
Since the report by Roberts and colleagues (1) in 1983, we
found 5 additional case reports of patients with AMI complicated by LV free wall rupture and/or aneurysm in patients with
AS (2–6). The findings in them are summarized in the Table 1,
which also includes the initial report by Roberts et al (1). No
reported cases were found in the search for AMI associated
with AS irrespective of whether an LV free wall rupture and/
or aneurysm was present. At the time of AMI, the 6 patients
ranged in age from 57 to 74 years (mean 64); 4 were women and
2 were men. The rupture site in all patients was the LV free wall,
leading to hemopericardium. The interval from onset of AMI to
Proc (Bayl Univ Med Cent) 2017;30(2):161–162
rupture ranged from 1 to possibly 30 days. The AS appeared to
be severe in all patients: the peak LV systolic gradients (reported
in 4 patients) ranged from 50 to 177 mm Hg.
DISCUSSION
When AMI occurs in patients with systemic hypertension,
the systemic arterial and LV pressures generally return to or
toward normal if the AMI is fairly large. Several reports have
demonstrated that systemic hypertension unassociated with
From the Baylor Heart and Vascular Institute and the Departments of Internal
Medicine and Pathology, Baylor University Medical Center at Dallas (Roberts); and
Texas College of Osteopathic Medicine, Fort Worth, Texas (Sheikh).
Corresponding author: William C. Roberts, MD, Baylor Heart and Vascular
Institute, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas,
TX 75246 (e-mail: [email protected]).
161
AS in patients with AMI is not a risk factor for LV free wall
rupture and/or aneurysm formation (2, 3). When AMI occurs
in patients with significant AS, however, the LV systolic pressure
remains elevated and the continuation of this elevation appears
to increase the likelihood of LV rupture and/or aneurysmal formation, particularly when the AMI involves the LV apical wall,
which normally is several times thinner than the LV basal wall.
There is some data on the frequency of AS in older populations and on the frequency of AMI and sudden cardiac death
among patients with AS. In an autopsy study, Roberts and
Shirani (7) found severe AS to be present in 43 (11%) of 391
patients aged 80 to 89 years, in 8 (9%) of 93 patients aged 90
to 99 years, and in 0 of 6 patients aged ≥100 years, or in 51
(10%) of the total 490 patients aged 80 years or over. Of the
490 autopsied patients, 229 (47%) had acute and/or healed
myocardial infarcts. Aronow and colleagues (8) studied by echocardiogram 1797 older patients (mean age 82 years) and found
AS in 301 (17%)—severe in 40, moderate in 96, and mild in
165. Among their 301 patients with AS, 158 (52%) had had
an earlier AMI that healed, and 217 (72%) had a new AMI or
died suddenly. There was no mention of LV free wall rupture or
LV aneurysm. There have been at least 2 case reports of AMI in
patients with AS and normal epicardial coronary arteries (9, 10).
Neither had LV free wall rupture or aneurysm.
The major limitation of this minireview is that the number
of patients with AMI associated with AS without LV free wall
rupture or LV aneurysm is entirely unknown. Conversely,
the reported cases of LV free wall rupture and/or aneurysm
complicating AMI in patients with AS may represent, of course,
the tip of the iceberg.
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1.
Roberts WC, Arnett EN, Aisner SC, Techlenberg P. Aortic valve stenosis
and left ventricular apical aneurysm and/or rupture: real or potential
complications of persistent left ventricular systolic hypertension after
acute myocardial infarction. Am Heart J 1983;105(3):513–514.
2. Duke M. Aortic stenosis, myocardial infarction and cardiac rupture: an
unusual triad. Tex Heart Inst J 1984;11(1):96–97.
3. Connery CP, Dumont HJ, Dervan JP, Hartman AR, Anagnostopoulos CE.
Transmural myocardial infarction with coexisting critical aortic stenosis
as an etiology for early myocardial rupture. J Cardiovasc Surg (Torino)
1994;35(1):53–56.
4. Kadri MA, Kakadellis J, Campbell CS. Survival after postinfarction cardiac
rupture in severe aortic valve stenosis. Eur Heart J 1994;15(1):140–142.
5. Ikeda M, Ohashi H, Tsutsumi Y, Kawai T, Ohnaka M. Endoventricular
circular patch plasty with aortic valve replacement for post-infarction
cardiac rupture complicated with aortic valve stenosis: case report. Circ J
2002;66(10):974–976.
6. Tanaka M, Goto Y, Suzuki S, Morii I, Otsuka Y, Miyazaki S, Nonogi H.
Postinfarction cardiac rupture despite immediate reperfusion therapy in a
patient with severe aortic valve stenosis. Heart Vessels 2006;21(1):59–62.
7. Roberts WC, Shirani J. Comparison of cardiac findings at necropsy
in octogenarians, nonagenarians, and centenarians. Am J Cardiol
1998;82(5):627–631.
8. Aronow WS, Ahn C, Shirani J, Kronzon I. Comparison of frequency of
new coronary events in older persons with mild, moderate, and severe
valvular aortic stenosis with those without aortic stenosis. Am J Cardiol
1998;81(5):647–649.
9. Jondeau G, Dubourg O, Partovian C, Dib JC, Lacombe P, Chikli F,
Bourdarias JP. Acute myocardial infarction in a patient with severe aortic
stenosis and normal coronary arteries. Eur Heart J 1994;15(5):715–717.
10. Lin CF, Chu KC. Acute myocardial infarction in an elderly patient with
severe aortic stenosis and angiographically normal coronary arteries. Int
J Gerontol 2010;4(3):157–160.
Baylor University Medical Center Proceedings
Volume 30, Number 2