Sequential development of multiple mechanical complications of myocardial infarction.

A71-year-old man with a medical history of hypertension and chronic renal failure presented to the emergency room with chest discomfort and dyspnea for 12 hours. The findings of the ECG (Figure 1) showed acute inferolateral ST-segment elevation myocardial infarction. The first troponin-I, creatine phosphokinase, and creatine kinase (CKMB) measurements were 19.3 ng/mL, 575U/L, and 68.6 ng/mL, respectively. Coronary catheterization revealed a right dominant coronary system with 70% middle-segment thrombotic occlusion of the right coronary artery. A successful percutaneous transluminal coronary angioplasty of the right coronary artery with the placement of a drug-eluting stent was performed. Twenty-four hours after the procedure, the patient complained of dyspnea, and consequent transthoracic echocardiography suggested the presence of a left ventricle inferolateral pseudoaneurysm. A cardiac MRI study was performed and revealed the presence of a transmural infarct ( 75%) involving the inferior wall, with no evidence of viability. It also showed an aneurysmal dilatation of the inferolateral segments, with signs of contained myocardial rupture at the left atrioventricular groove (Figure 2A and 2B). The patient was emergently taken to the operating room. Intraoperative inspection confirmed the diagnosis of contained myocardial rupture surrounded by an extensive area of myocardial hemorrhage. The rupture was repaired on cardiopulmonary bypass using a tailored Dacron patch. On postoperative day 2, a transthoracic echocardiography and transesophageal echocardiography primarily performed