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

Abstract

Amid the coronavirus disease 2019 (COVID-19) pandemic, there is an unprecedented increase in public avoidance of hospitals predominantly driven by fear of contracting the virus. Recent publications highlight a re-emergence of rare post–myocardial infarction complications. While mechanical complications are infrequent in the era of primary percutaneous coronary intervention, they are associated with high mortality rates. The concurrent occurrence of mechanical complications such as left ventricular aneurysm and ventricular septal rupture is an extremely rare entity. We hereby delineate a unique case of a 53-year-old Caucasian male who underwent successful concomitant closure of a ventricular septal rupture, left ventricular aneurysmectomy, and 3-vessel coronary artery bypass grafting. Due to a delayed initial presentation owing to the patient’s fear of contracting COVID-19, the surgery was carried out 3 months after the myocardial infarction. His postoperative evaluation confirmed normal contractility of the left ventricle and complete closure of the ventricular septal rupture. Six months postoperatively, the patient continues to do well. We also present a literature review of the mechanical complications following delayed presentation of myocardial infarction amid the COVID-19 pandemic. This article illustrates that clinicians should remain cognizant of these extremely rare but potentially lethal collateral effects during the ongoing global public-health challenge. Furthermore, it highlights a significant concern regarding the delay in first medical contact due to the reluctance of patients to visit the hospital during the COVID-19 pandemic.

A new dimension to the STEMI-related mortality risk seen in the COVID-19 pandemic era

“…Clinical and echocardiographic recognition of VSR coinciding with electrocardiographic recognition of STEMI ( Table 1 ). In this category there were 42 cases [ [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] ] (28 males) of mean age 67. The period of pre-hospital delay ranged from 6 h to 3 months.…”

“…The period of pre-hospital delay ranged from 6 h to 3 months. Twelve cases had a pre-hospital delay of 7 days or more [ [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] ].…”

“…Five patients had coexisting VSR and left ventricular aneurysm [ 10 , 11 , 13 , 36 , 40 ],. Two patients had coexisting VSR and left ventricular pseudo aneurysm [ 32 , 41 ].…”

Multimodality Imaging of Sudden Cardiac Death and Acute Complications in Acute Coronary Syndrome

“…Although uncommon, aneurysms and pseudoaneurysms (PAN), which derive from an incomplete rupture of the LV free wall, may occur after ACS and have a high mortality rate up to 20% [ 66 ]. Aneurysms are located in the left ventricle apex in 80% of cases, while PANs are typically located is the anterior or lateral wall of the LV [ 67 ]. Echocardiographic features are the following: a cavity which communicates with the LV chamber through a large (aneurysm) or tight (PANs) neck; a thrombus into either aneurysms or PANs may be found; doppler and color flow imaging may show bidirectional blood flow via the site of rupture [ 68 ].…”

Mechanical complications of ST segment elevation myocardial infarction: are they tangible?

“…Most common phenomenon regarding mortality after successful PCI is mechanical complication after revascularization. Mechanical complication comprises left ventricular free-wall rupture, ventricular septal defect (VSD), papillary muscle rupture, pseudo-aneurysm, true aneurysm, and post-myocardial infarction pericarditis (8)(9)(10). Throughout the years many researchers have investigated the prognosticators regarding STEMI.…”