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A 79 year old woman was admitted to hospital because of acute, severe chest pain of 12 hours' duration. She had known coronary three vessel disease with prior coronary artery bypass surgery 19 year ago. In the coronary care unit, the ECG showed complete left bundle branch block and subacute myocardial infarction (creatine kinase 3903 U/l) was diagnosed. Because of the time delay, no thrombolysis was given but the patient received tirofiban and heparin until the next day when coronary angiography was performed. All bypasses were open and all major native vessels occluded, so coronary angioplasty was not feasible. Four days later, while taking a shower on the ward, the patient suddenly experienced a severe pain in her left flank. Left heart failure developed (no new creatine phosphokinase rise occurred). Subsequent echocardiography showed myocardial rupture (maximal diameter of entry 1.5 cm) of the hypokinetic inferolateral wall with effusion contained by the pericardium (pseudoaneurysm formation) as shown: A, apical long axis view showing rupture site of the inferolateral wall with pericardial effusion (PE, pericardial effusion; AO, aorta; LA, left atrium; LV, left ventricle); B, colour Doppler flow image showing blood flow from the left ventricle through the rupture site into the pseudoaneurysm or pericardial effusion, respectively; C, immediately after intravenous contrast injection, the left ventricular cavity is filled with contrast; D, within one minute after contrast injection, contrast enhancement is seen within the pericardial effusion. Cardiac surgery was refused by the patient. After seven days the echocardiographic findings were unchanged. Twelve days later the patient went home. Myocardial rupture is a known fatal complication of myocardial infarction occurring especially in women, elderly patients and in first or inferior myocardial infarction. Left ventricular pseudoaneurysms form when myocardial rupture is contained by adherent pericardium or scar tissue. Free intrapericardial rupture usually results in cardiac tamponade and death. Because of this patient's previous bypass surgery there were pericardial adhesions and so the rupture was contained, which enabled pseudoaneurysm formation and thus survival.
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