Communicating Neo-chamber in the Left Ventricle and a Remote Intramyocardial Hematoma Following Acute Myocardial Infarction

Madhu Shukla; Jagdish Chander Mohan

doi:10.4103/jiae.jiae_4_23

INTERESTING CASE REPORT

Year : 2023 | Volume : 7 | Issue : 2 | Page : 185-188

Communicating Neo-chamber in the Left Ventricle and a Remote Intramyocardial Hematoma Following Acute Myocardial Infarction

Madhu Shukla, Jagdish Chander Mohan
Department of Cardiology, Institute of Heart and Vascular Diseases, Jaipur Golden Hospital, New Delhi, India

Date of Submission	11-Jan-2023
Date of Acceptance	08-Feb-2023
Date of Web Publication	05-Apr-2023

Correspondence Address:
Jagdish Chander Mohan
A-51, Hauz Khas, New Delhi - 110 016
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_4_23

Abstract

This report describes a 68-year-old female who, immediately after the primary percutaneous coronary intervention of the left anterior descending artery for acute anterior myocardial infarction, developed an apical aneurysm and a “neo-chamber” within the left ventricular cavity separated from the main cavity by a linear thick hyperechoic free-floating fenestrated membrane. This was an excoriated but perforated subendocardial spiral myocardial layer separated from the subepicardial layer due to ischemia and infarction. Multiple orifices on the inner surface were observed, possibly due to patchy necrosis. In addition, there was a large remote intramyocardial hematoma in the inferolateral wall of indeterminate pathogenesis.

Keywords: Acute myocardial infarction, double-chambered left ventricle, myocardial dissection

How to cite this article:
Shukla M, Mohan JC. Communicating Neo-chamber in the Left Ventricle and a Remote Intramyocardial Hematoma Following Acute Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging 2023;7:185-8

How to cite this URL:
Shukla M, Mohan JC. Communicating Neo-chamber in the Left Ventricle and a Remote Intramyocardial Hematoma Following Acute Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2023 [cited 2023 Sep 27];7:185-8. Available from: https://jiaecho.org/text.asp?2023/7/2/185/373604

Introduction

Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic split among the spiral myocardial fibers due to ischemia. In anterior myocardial infarction, left ventricular (LV) apical dissection and hematoma have been reported infrequently with blood-filled neo-cavity formation, inner thin undulating hypermobile membrane-like wall, and outer thick subepicardial layer.^{[1],[2],[3],[4],[5],[6],[7]} These are differentiated from pseudoaneurysms which have only epicardium or visceral pericardium as the outer covering and communicate with the main cavity through a narrow neck which sometimes may get covered with a thrombus. Lack of direct communication between the LV and the echo-lucent blood-filled intramyocardial cavity is a common feature of dissecting intramural hematoma. We present an interesting case wherein hemorrhagic dissection separated the infarcted subendocardial muscular layer from the subepicardial spiral layer with necrotic fenestrations of the former that communicated with the main LV cavity. The case is reported for its unique imaging features.

Case Report

A 68-year-old average-built diabetic woman presented at midnight with acute anterior wall myocardial infarction and right bundle branch block with left anterior fascicular block and underwent successful uncomplicated primary percutaneous coronary intervention of the proximal left anterior descending artery with stent implantation within a window period of 2 h with partial resolution of ST-segment elevation [Figure 1]. In the morning, 3 h after coronary intervention, she developed complete heart block, for which she was put on a temporary pacemaker. Normal atrioventricular conduction was restored in 3 days, and she declined permanent pacemaker implantation. Screening two-dimensional echocardiography performed at admission showed LV apical dyskinesis, an estimated ejection fraction of about 40%, and no intracavitary mass. Detailed three-dimensional (3D) echocardiographic examination on the next day showed apparently double-chambered LV with a partitioning thick but fenestrated structure (excoriated subendocardial infarcted muscular layer) [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Video 1]. Multiple echocardiographic views revealed a large mobile fenestrated flap of variable thickness in the LV, dividing it into basal inferoposterior and apicoanterior chambers. LV ejection fraction measured after microbubble contrast injection was 28% and global longitudinal strain was -5.5%. Color Doppler interrogation showed blood flow across the thick membrane through the fenestrations. Injection of definity contrast showed opacification of the entire cavity with faint visualization of the partition [Figure 4]. Apical segments showed dyskinesis with thin surrounding walls. In addition, an echo-lucent neo-cavity (1.0 cm × 1.8 cm) was observed in the thickened basal inferolateral wall, which expanded longitudinally toward papillary muscle during diastole [Figure 6] and [Video 2]. All the apical segments showed a lack of perfusion in myocardial contrast imaging [Video 3]. Multiplanar reconstruction of 3D images showed two distinct cavities [Video 4].

Figure 1: Left coronary angiogram in anteroposterior caudal view showing occluded proximal left anterior descending artery (arrow) (a) and patent vessel following stent implantation (b). LAD: Left anterior descending artery. LCX: Left circumflex artery

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Figure 2: Transthoracic echocardiographic apical four-chamber view in systole (a) and in diastole (b) showing double-chambered left ventricle with a visible hole (arrows). LA: Left atrium, LV: Left ventricular, RA: Right atrium, RV: Right ventricle

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Figure 3: A muscular ridge (yellow arrows) partitioning the left ventricular cavity seen in transthoracic echocardiographic apical two-chamber view (a), parasternal long-axis view (b), apical five-chamber view (c), and in the obliquely reconstructed short-axis view (d). C1 and C2 refer to the two cavities within the left ventricle. 2CV: Two-chamber view, PLAX: Parasternal long-axis view

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Figure 4: Transthoracic echocardiographic four-chamber view without definity contrast (a) and with contrast injection (b) showing chamber partition (arrows) with contrast present in both chambers

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Figure 5: Longitudinal multiplane reconstruction of three-dimensional data set showing partitioning of the left ventricular cavity by a thick membrane (arrows). LA: Left atrium

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Figure 6: Transthoracic echocardiographic parasternal long-axis view showing an echo-lucent space (H) in the basal inferolateral wall (red arrow) which is markedly thickened. Yellow arrow points to the dividing tissue ridge away from the basal neo-cavity. AO: Aorta, LA: Left atrium, LV: Left ventricular

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[Additional file 1]

Video 1: Transthoracic echocardiographic apical four-chamber view showing an appearance of double-chambered left ventricle.

[Additional file 2]

Video 2: Parasternal long-axis view showing intramyocardial hematoma in the inferolateral wall.

[Additional file 3]

Video 3: Apical four-chamber view with cavity opacification with Definity ultrasound contrast.

[Additional file 4]

Video 4: Reconstructed views from three-dimensional dataset showing double-chambered left ventricle in the long- and short-axis.

Conservative treatment was planned after a discussion with the patient.

Discussion

Dissecting myocardial hematoma (DMH) is a type of cardiac rupture that occurs following myocardial infarction.^[1] Cardiac rupture of the free wall toward the pericardial cavity can cause sudden death or the formation of a pseudoaneurysm if contained by the epicardium. Rupture can also occur within the two layers of the myocardium with the collection of blood and a neo-cavity formation which does not communicate with the LV cavity and is labeled DMH. If DMH ruptures in the cavity at one or more points, it gives an appearance of double-chambered LV, as in our case.

Double-chambered LV is a term that has been used to describe the subdivision of LV as a result of anomalous septum or muscle bundle.^[7] In most reports, however, abnormal muscle band attached to the LV lateral wall or within the apex has been described, which definitely separates the LV cavity into two parallel chambers, both connected by a common outflow segment.^[7] Myocardial dissection following acute myocardial infarction or secondary to reperfusion injury may separate the LV cavity into apical and basal parts transversely or obliquely.^{[1],[2],[3],[4],[5]} However, the two cavities may or may not communicate. All previous reports have shown a lack of communication between the two cavities, and the myocardial flap facing the LV cavity is imperforate. The present case is unique because it shows a fenestrated myocardial dissection flap consisting of subendocardial necrotic muscle fibers along with free nonobstructive communication between the two cavities, as shown by color Doppler and microbubble contrast injection. In addition, there was a remote intramyocardial hematoma in the inferolateral wall which could either be a result of dual anti-platelet therapy or external cardiac massage during ventricular asystole which occurred a few hours after the angioplasty or even spontaneous. Blunt chest trauma has been reported to cause intramyocardial hematoma.^[8]

Conclusion

Cardiac rupture following acute myocardial infarction can be extracavity or rarely intracavity. Intracavity myocardial rupture can present as a neo-chamber within the LV with a definite communication between the two parts and can be differentiated from dissecting intramyocardial hematoma by color Doppler flow mapping and contrast imaging.

Learning objectives

To recognize that reperfusion injury following acute myocardial infarction can present as a communicating neo-chamber within the LV that is different from dissecting intramyocardial hematoma
To understand that rarely intramyocardial hematoma can occur in remote myocardium after percutaneous interventions in acute myocardial infarction due to multiple mechanisms.

Authorship

Both authors equally contributed to the management of patients and preparation of case reports.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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