P178 Dissecting ventricular septal hematoma; a rare complication of acute myocardial infarction

Abstract

Ischemic heart disease is the single most common cause of mortality worldwide despite the widespread use of reperfusion. The in-hospital mortality rates of unselected patients with STEMI in national European registries vary between 4–12%.Although the incidence of mechanical complications has declined, these adverse events are still inevitable and constitute one of the major causes of death in the early phase after myocardial infarction. Dissecting interventricular hematoma is a rare life threatening mechanical complication following myocardial infarction. The resultant bleeding dissects along a plane beneath the endocardium. Case presentation A 57 year old male patient presented to the emergency room complaining of acute stabbing retrosternal chest pain radiating to both shoulders associated with nausea and vomiting that started 2 hours before presentation. He was known to be smoker and diabetic and had uncontrolled hypertension. Vital signs were stable and physical examination was unremarkable . Electrocardiography (ECG) revealed normal sinus rhythm at 80 bpm, 5 mm ST elevation in leads I, aVL, V1-V6, reciprocal ST depression in leads II, III,aVF. The patient received thrombolytic therapy within 15 minutes of presentation and it was uneventful. Follow up electrocardiography was done showing failed thrombolytic therapy. The patient was managed conservatively using dual antiplatelets, high dose atorvastatin, beta blockers, ACE inhibitors. The patient remained hemodynamically stable for 5 days after which he developed respiratory distress , heart rate was 110 bpm, blood pressure was 100/60 mmHg. Physical examination revealed clear chest ,S3 gallop. 2D/ 3D transthoracic echocardiography revealed akinesis of the apical segments and mid segment of the anterior septum. There was a dissecting hematoma seen starting at mid anterior septum and extending to the apical segment.Severe mitral valve regurgitation was seen. Conclusion Dissecting interventricular hematoma(DIH) is a rare yet underrecognized mechanical complication following STEMI. Transthoracic echocardiography is considered to be an important imaging modality for the bedside diagnosis. Treatment depends upon the rate of expansion of hematoma. Accordingly, stable patients with hematoma regressing gradually does not require any intervention .However, cases with rapidly expanding hematoma with hemodynamic instability will require urgent surgical intervention. Abstract P178 Figure. Dissecting interventricular hematoma

Evolution of Interventricular Septal Hematoma: Echocardiographic Diagnosis

“…14 Three-dimensional echocardiography demonstrates regional akinesia of the ventricular septum. 15 In a rare case of spontaneous IVSH with endocardial fibroelastosis, cardiac magnetic resonance imaging in addition to echocardiography was useful in myocardial tissue characterization. 16 Ventricular cine angiography demonstrated accumulation of contrast within the IVSH 14 and identified injury to the first septal perforator artery.…”