HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

BACKGROUND:
No known drug allergies.
Cardiovascular risk factors (CVRF): High blood pressure (HBP) under treatment and smoker of one pack a day.
No relevant medical history.
Previous surgeries: appendectomy 20 years ago.
Current treatment: enalapril 10 mg every 12 hours. Baseline life: independent for basic activities of daily living.
Family history: father with sudden death at the age of 60.

CURRENT ILLNESS:
44-year-old male patient brought by SUMMA to the emergency department for sudden syncope recovered while walking in the street. He reported atypical chest pain in the previous 72 hours, intermittent, which appeared at rest and was not accompanied by vegetative cortex. There were no symptoms of heart failure or palpitations. No other clinical manifestations due to apparatus. On arrival at the emergency department, an electrocardiogram (ECG) was performed. Haemodynamically unstable, urgent TTE was performed, showing cardiac tamponade secondary to cardiac rupture. Orotracheal intubation was performed, a central line was placed, inotropic support was started and pericardiocentesis was performed but failed, and the cardiac surgeon was notified for urgent surgery to evacuate the effusion and implant a pericardial patch. After surgery, he was admitted to the intensive care unit (ICU) for further care. During his admission to the ICU, coronary angiography was performed showing left coronary artery without significant lesions and critical stenosis of the proximal right coronary artery (RCA), with image of partially recanalised thrombus and distal TIMI 1 flow, to IVP is partially filled by collateral circulation from IC. Medical treatment of the lesion was decided for the time being. After a month of hospitalisation, extubated, clinically and haemodynamically stable, he was discharged to the cardiology ward.

PHYSICAL EXAMINATION:
IOT, regularly perfused, tachypneic. Cardiac auscultation: rhythmic, tachycardic, no murmurs, muffled tones. Pulmonary auscultation: bilateral crackles. Lower limbs: no oedema.

COMPLEMENTARY TESTS
ANALYTICS: Hb 10g/dl. Platelets 228.000/ml, leukocytes 26.000/ml. 89% neutrophils. INR 1.7. Urea 32 mg/dl. Cr 0.76 mg/dl. Na 136. K 4.3 mEq/l. pH 7.21, lactic 1.2 mmol/l, CK 3,000 mmol/l, TnT 600 ng/dl.
Urgent TTE (postoperative, ICU): severe biventricular dysfunction at the expense of inferior and inferolateral akinesia and dyskinesia of the basal segments. Mild ischaemic mitral insufficiency (MI). Mild pericardial effusion.
CORONARYGRAPHY: critical proximal DC stenosis, with image of partially recanalised thrombus, and distal TIMI 1 flow. IVP is filled by collateral circulation from the left coronary artery. Left coronary tree without significant lesions.
TTE ruled (cardiology floor): severely dilated left ventricle (LV).
Severe LV dysfunction with hypokinesia of all segments and akinesia of the inferior face, large posterobasal aneurysm with partial thrombosis of the cavity. Right ventricular (RV) systolic function at the lower limit of normality.
MRI (cardiology floor): dilated LV with large lateral wall pseudoaneurysm, at the level of surgical repair of LV free wall rupture. The pseudoaneurysm measures: 66 x 41 mm (lateral and inferolateral extension). There are no images suggestive of thrombus inside the pseudoaneurysm. Lateral wall thinned, with lateral and inferior akinesia. The rest of the walls with septal thickness within the normal range. Contractility preserved at the level of the anterior wall, septum and mid-apical and basal lateral wall. Global systolic function severely depressed 19%. Late gadolinium enhancement study with transmural enhancement area in inferior and lateral face respecting apical segments of both faces. RV with size, thickness and global and segmental contractility within normal limits. Global systolic function lower limit of normality (51%). Left pleural effusion.

Conclusions:
LV with large lateral and inferolateral pseudoaneurysm with lateral and inferior akinesia.
Global systolic function severely depressed.
Transmural enhancement in inferior and lateral face respecting apical segments of both faces.
Left pleural effusion. Lateral and inferolateral pseudoaneurysm 66 x 41mm.
Transmural enhancement in inferior and lateral face, respecting apical segment of both faces. LVEF 20%. Intracavitary thrombus.
CT scan (cardiology ward): ascending thoracic aorta: 30 x 32 mm. Descending thoracic aorta: 20 x 20 mm. Findings: on the inferolateral side, a ventricular pseudoaneurysm is identified, consisting of a rupture contained by a surgical patch of pericardium, measuring 64 x 41 x 73 mm with a neck of 54 x 59 mm (measured from the basal and papillary segment). The pericardial patch cannot be properly individualised and the most apical portion of the structure could be constituted by myocardial wall. The papillary muscle has its base just distal to the pseudoaneurysm. A 4 mm filling defect is identified inside the pseudoaneurysm, which could correspond to a small thrombus. No pericardial effusion was detected. No other extracardiac findings. Summary: Inferolateral ventricular pseudoaneurysm measuring 64 x 41 x 73 mm with a neck of 54 x 59 mm (see description). Small intracavitary thrombus. Absence of pericardial effusion.

CLINICAL EVOLUTION
In the cardiology ward, complementary tests were carried out and showed, in summary, severe ventricular dysfunction with pseudoaneurysm in the LV measuring 66 x 41 mm. Treatment was optimised and enalapril 10 mg c/12 hours, metoprolol 50 mg c/12 hours, aldactone 25 mg c/24 hours and ivabradine 7.5 mg c/12 hours were prescribed with good tolerance.
The case was presented at a medical-surgical session where the following options were proposed: medical treatment and follow-up, implantation of an implantable cardioverter defibrillator (ICD), surgical resection of the pseudoaneurysm and cardiac transplant.
Finally, it was decided to resect the pseudoaneurysm with very good clinical evolution and follow-up in consultations. Currently, the patient has recovered LVEF to 42% in the last TTE with New York Heart Association (NHYA) functional class I and free of admissions since discharge.

DIAGNOSIS
Inferolateral acute myocardial infarction (AMI) complicated by cardiac rupture. Pericardial patch repair.
Large lateral wall pseudoaneurysm, at the level of surgical repair of LV free wall rupture. Surgical resection of pseudoaneurysm.
Severe ventricular dysfunction, currently moderate.
