History of Presentation

A 70-year-old male presented to the emergency department with progessively worsening chest pain, palpitations and shortness of breath for four hours. In the past three months, he complained of exertional chest pain that settled at rest and was compliant with his anti-anginal medications. His observations were significant for blood pressure 70/30 mmHg and a sinus tachycardia of 125 beats per minute. On examination he was confused and had signs of poor peripheral perfusion with cool lower extremities, elevated jugular venous pressure, muffled heart sounds and pulsus paradoxus. The patient had known hypertension of which he was on losartan 50 mg once a day. He had a history of heavy smoking for the past 40 years and did not have previous coronary intervention or cardiac surgery.

An initial electrocardiogram (ECG) revealed inferolateral ST segment elevation (Figure 1A). Significant blood test findings were a raised troponin T of 2,000 ng/L (TnT 14-30 ng/L), negative inflammatory markers (C-reactive protein 0.5 mg/dl, white blood cells 6.0 × 10³/ul) and normal kidney function. Given the patient’s unstable hemodynamic state, an immediate bedside transthoracic echocardiogram (TTE) was performed that showed inferior posterior wall hypokinesia, an extensive echo-dense pericardial effusion with right ventricular collapse and inferior vena cava pleathore was observed (Figures 2A to D and Video 1). This prompted an emergency coronary angiogram that demonstrated occlusion of the distal circumlex artery and moderate disease of the diagonal artery (Figures 1B and 1C). Valvular pathology was not seen on TTE. Cardio-thoracic surgery was then consulted as findings of the TTE raised suspicion of right ventricular free-wall rupture (RV FWR) resulting in cardiac tamponade, thereby explaining the elevated troponin and patient symptoms.

The patient was initially hemodynamically stabilised with noadrenaline and dopamine. We sought an urgent cardiothoracic surgery consultation that concluded with emergency surgery given the patient’s persistant hypotension, TTE findings and only distal circumflex occlusion on angiogram not amenable to percutaneous intervention. During surgery, after median sternotomy, a significant amount of pericardial hematoma was removed and an RV FWR was seen near the posterior interventircular sulcus (Figure 2E) and repaired by suturing with pledgets (Figure 2F). The procedure was performed on-pump in the arrested heart. Further attempt to revascularise the distal circumlex artery was not considered as most of the territory appeared to be infarcted.

The patient was extubated 24 hours after surgery and inotropic support was weaned. Post-operative TTE showed improvement of left ventricular ejection fraction to 50% with minimal pericardial effusion (Figure 2D and Video 2). The post-operative course was uneventful and the patient was discharged 8 days after surgery. At the 1-month follow-up appointment, his symptoms had completly resolved and a repeat TTE showed no further change in ejection fraction or pericardial fluid size. He remained on optimal heart failure medical therapy and will have a follow-up TTE in 12 months.