72 Novel approach of managing left ventricular wall rupture as a complication of late presentation myocardial infarction

Left ventricular free wall rupture is a serious complication that could occur in patients following a myocardial infarction. The survival rate of patients presenting with such a condition are largely unfavorable. In the below case we discuss the approach we took which led to the survival of one such patient.A 54-year-old gentleman was admitted to hospital following a collapse in public, where he turned grey and became unresponsive. He had no cardiac history but reported chest pain five days prior. His past medical history included severe spondylitis and he was an active smoker. On arrival to hospital, he was haemodynamically unstable with a blood pressure of 63/48 mmHg and heart rate of 111 beats per minute. 12 lead electrocardiogram (ECG) showed ST-segment elevation in inferior leads with established Q waves and blood troponin levels of 33,000 (see figure 1). A provisional diagnosis of cardiac tamponade due to left ventricular (LV) rupture was made, which was confirmed via an echocardiogram showing extensive pericardial effusion and clots (see figure 2). An angiogram showed that the occlusion was in the distal left circumflex artery and an emergency intra-aortic balloon pump (IABP) was inserted due to hemodynamic compromise. Transesophageal echocardiogram was unsuccessful due to difficulty in advancing the probe as the patient had a fixed neck with kyphosis.Once the patient was stabilised, the decision for emergency surgery was taken as a definite measure. Cardiopulmonary bypass was established peripherally under local anesthetic with femoral-femoral bypass, as intubation was contraindicated due to the fixed neck. Once on full bypass, the patient was sedated, intubated, and had a sternotomy. The left ventricular (LV) wall rupture was visualized at the mid ventricle, along with evidence of fresh myocardial infarction (MI) laterally. However, the heart anatomy and orientation of great vessels were abnormal due to the severity of kyphosis. The rupture of the left ventricle was immediately repaired on beating heart bypass without cross clamping the aorta. The repair was successful, and two drains were inserted into the right pleural cavity and mediastinum. Post-surgery transthoracic echocardiography confirmed resolution of pericardial effusion and repair of the left ventricle wall. The patient made an uneventful recovery and was subsequently discharged home.Learning objectives:1.Suspect myocardial infarction complication such as left ventricle wall rupture in