Free wall ruptures occur in 0.01% of the STEMI and NSTEMI populations.They can be repaired by various techniques, depending on anatomical location and tissue quality. A 62-year-old female presented with chest pain and syncopal episodes post alleged assault. Her ECG showed inferior ischaemia. Medical history included active smoking, systemic lupus erythematosus and autoimmune haemolytic anaemia requiring immunosuppression.
Aspirin and ticagrelor were commenced for acute coronary syndrome. Angiogram confirmed right coronary artery proximal occlusion with suspected spontaneous dissection. Percutaneous interventions were unsuccessful. Transthoracic echocardiogram(TTE) revealed a contained left ventricular(LV) mid inferior myocardial rupture with tamponade physiology. She was transferred via air to a tertiary centre 100km away. The patient rapidly deteriorated with multiorgan dysfunction; emergent surgery was performed peri-arrest. Peripheral cardiopulmonary bypass was commenced prior to median sternotomy. A large haemopericardium was drained. The inferior myocardial wall was boggy and friable with significant haematoma. A pseudoaneurysm was present at the LV/RV junction inferiorly. A bovine pericardial patch was secured using bioglue alone due to tissue fragility and challenging access. She was transferred to intensive care on VA ECMO facilitating end organ and cardiac recovery. TTE 6 weeks post repair demonstrated normal LV/RV function.
We discuss how tissue quality, timing from ischaemic incident and anatomical location determine the best methods of repair.