Confirmed early myocardial rupture in a patient with pulseless electrical activity (PEA) following late presentation of ST elevation myocardial infarction

Baskar Sekar, Joe Martins, Sanjiv Petkar

A 69 year old male, an ex-smoker, was admitted with ongoing chest pain of 11 hours duration. Past medical history included treated hypertension and gastro-oesophageal reflux disease. He delayed seeking medical attention as he assumed the pain to be due to indigestion and kept taking antacids without much symptomatic relief. Clinical examination on arrival was unremarkable. Admission 12 lead electrocardiogram (ECG) was diagnostic of a recent anterolateral myocardial infarction (MI) (Figure 1a). Bedside trans-thoracic echocardiogram (TTE) confirmed an established anterolateral MI (Video 1, Figure 1b). Unfortunately, en route to the cardiac catheter laboratory for a primary percutaneous coronary intervention (PPCI), he suffered a cardiac arrest, due to pulseless electrical activity. An urgent repeat TTE confirmed significant pericardial effusion due to myocardial rupture with thrombus in the left ventricular apex (Figure 1c, Video 2). Attempts at resuscitating him were unsuccessful. It is rare to see and confirm a diagnosis of early myocardial rupture outside the autopsy room, as it is an extremely serious and lethal mechanical complication of acute MI. PEA in a patient with a first MI and without overt heart failure has a high predictive accuracy for this diagnosis. Anterior location of MI, age >70 years, and female sex are risk factors for myocardial rupture, while a patent infarct related artery, either after PPCI or fibrinolytic therapy appears to be protective. As in this case, when time allows, TTE plays an invaluable role in diagnosing this condition.