Left ventricular free wall rupture as a result of delayed presentation of an inferior ST-elevation myocardial infarction due to fear of COVID-19: case report

Abstract

Background Left ventricular free wall rupture (LVFWR) is a rare complication after myocardial infarction and usually occurs 1 to 4 days after the infarct. Over the past decade, the overall incidence of LVFWR has decreased given the advancements in reperfusion therapies. However, during the COVID-19 pandemic, there has been a significant delay in hospital presentation of patients suffering myocardial infarctions, leading to a higher incidence of mechanical complications from myocardial infarctions such as LVFWR. Case presentation We present a case in which a patient suffered a LVFWR as a mechanical complication from myocardial infarction due to delay in seeking care over fear of contracting COVID-19 from the medical setting. The patient had been having chest pain for a few days but refused to seek medical care due to fear of contracting COVID-19 from within the medical setting. He eventually suffered a cardiac arrest at home from a massive inferior myocardial infarction and found to be in cardiac tamponade from a left ventricular perforation. He was emergently taken to the operating room to attempt to repair the rupture but he ultimately expired on the operating table. Conclusions The occurrence of LVFWR has been on a more significant rise over the course of the COVID-19 pandemic as patients delay seeking care over fear of contracting COVID-19 from within the medical setting. Clinicians should consider mechanical complications of MI when patients present as an out-of-hospital cardiac arrest, particularly during the COVID-19 pandemic, as delay in seeking care is often the exacerbating factor.

Simultaneous Left Ventricular Aneurysm and Ventricular Septal Rupture Complicating Delayed STEMI Presentation: A Case-Based Review of Post-MI Mechanical Complications Amid the COVID-19 Pandemic

“…Mechanical complications following delayed MI presentations were described in a total of 26 case reports only (level of clinical evidence: IV) in 21 selected articles included in this study, dating from June 2020 to May 2021. 7 - 27 No gender predominance was noted as the male-to-female ratio was 1:1). The age of patients ranged from 37 to 87 years (mean ± standard deviation = 64.12 ± 53.70 years).…”

“…The data regarding patient demographics, presenting symptoms, time from symptom onset to presentation, electrocardiographic features, anatomic findings, nature of mechanical complications, left ventricular ejection fraction, treatment, and clinical outcomes are summarized ( Table 3 ). 7 - 27…”

Cardiac Tamponade Secondary to Hemorrhagic Pericardial Effusion: A Complication of STEMI

“…Current literature supports cardiogenic shock and LVFWR as major causes of death following STEMI. [3][4][5][6][7][8][10][11][12][13][14][15][16][17] The dilemma that providers face when dealing with a hypotensive STEMI patient is trying to identify if the patient has cardiogenic shock from pump failure vs obstructive shock from hemorrhagic pericardium. Cardiogenic shock should be suspected when the echocardiogram reveals reduced left ventricular function and low ejection fraction.…”

“…5 However, the incidence of LVFWR and other mechanical complications of STEMI increased during the coronavirus disease 2019 pandemic as patients delayed seeking care out of fear of contracting the virus in the medical setting. 6,7 Providers should be aware of a pericardial effusion in the setting of STEMI, as a hemodynamically significant pericardial effusion has a significant impact on treatment approach. Patients with STEMI and benign pericardial effusion may safely proceed to the catheterization laboratory for revas-cularization.…”

Challenges in Management of ST Elevation Myocardial Infarction during COVID-19 Pandemic

“…Physicians may be more inclined to choose conservative management for some STEMI patients with borderline premorbid status. Furthermore, the delayed STEMI presentation precipitated a resurgence of post-MI mechanical complications such as ventricular septal defect, papillary muscle, and free-wall rupture[ 52 ],[ 53 ],[ 54 ] [Figure 3 ]. These invariably complicated patients' in-hospital course and worsened outcomes.…”