2022 Volume 86 Issue 2 Pages 332-
A 74-year-old woman complained of sudden-onset chest pain. She had a history of ascending aorta replacement owing to type A aortic dissection with cardiac tamponade 10 years ago. ECG showed ST elevation in the precordial leads. Contrast-enhanced computed tomography (CT) showed no pericardial effusion (Figure A). Coronary angiography revealed occlusion of the proximal left anterior descending artery (Figure B). Despite successful percutaneous coronary intervention, she remained in discomfort. Right heart catheterization revealed a pressure gradient between the right ventricle and pulmonary artery (Figure C), and right ventriculography showed obstruction of the right ventricular outflow tract (RVOT) and contrast leakage toward the left ventricle (Figure D, Supplementary Movie 1). Echocardiography demonstrated pericardial effusion, compressing the RVOT (Figure E, Supplementary Movie 2). Contrast-enhanced CT indicated loculated effusion that longitudinally extended around the RVOT (Figure F, yellow arrows), as well as tearing of the septal-free wall junction (Figure G), which caused ventricular septal rupture with free wall rupture.
(A) Initial contrast-enhanced coronal (Upper) and sagittal (Lower) computed tomography (CT). (B) Coronary angiography. (C) Pressure waveforms of the right ventricle (Left) and pulmonary artery (Right). (D) Right ventriculography showing obstruction of the RVOT (black arrows) and contrast leakage (red arrow). (E) Parasternal long-axis (Upper) and short-axis (Lower) echocardiography showing pericardial effusion compressing the RVOT (yellow arrows). (F,G) Series of sagittal contrast-enhanced CT images; yellow arrows show loculated effusion notably; there was no effusion around the posterior side of the ventricle (*, G). Red arrows show a tear. (H) The yellow arrow indicates RVOT compressed by the effusion. The red arrow indicates the tear of ventricle. LV, left ventricle; PA, pulmonary artery; RV, right ventricle; RVOT, right ventricular outflow tract.
Regarding the clinical presentation, pericardial adhesion due to a previous pericardial incision might prevent pericardial effusion from extending toward the posterior side of the ventricle and leading to longitudinal distribution. This case indicated that RVOT obstruction can be an atypical presentation of myocardial rupture in patients with pericardial adhesion.
M.Y. is a member of Circulation Journal’s Editorial Team.
Written informed consent was given by the bereaved family.
Supplementary Movie 1. Right ventriculography.
Supplementary Movie 2. Echocardiography.
Please find supplementary file(s);
http://dx.doi.org/10.1253/circj.CJ-21-0693
