Clinical Images

Case of a Broken Heart

Figure 1. EKG on admission

Figure 2. Echocardiogram demonstrating tear of the interventricular septum

Authors: Kavya Patel MD, Kartik Kalra MD, Osakpolor Ogbebor MD MPH MRCP(UK), Damodar Penigalapati MD

A 53-year-old male was admitted to the emergency room (ER) with a history of chest pain and dyspnea for 7 days. Prior to this, his history was only notable for hypertension. On arrival to the ER, his blood pressure was 69/54 mm Hg, Jugular Venous Pressure (JVP) was not elevated and auscultation revealed a normal S1 and S2 with loud 4/6 holosystolic murmur radiating to axilla. EKG showed ST elevations in V1-V5 leads (arrows in Figure 1).

Lab tests showed elevated liver enzymes: AST 1481 units/L (10-40 units/L), ALT 2018 units/L (7-56 units/L); impaired renal function with creatinine: 6.4 mg/dL (0.6-1.2 mg/dL); and elevated troponin: 16.7 ng/ml (<0.04 ng/ml). Bedside echocardiogram demonstrated hypokinesis of the anteroseptal wall with diminished ejection fraction (45%) and serpiginous tear of the interventricular septum (Figure 2). Emergency cardiac catheterization showed 100% of mid LAD and 90% of RCA occlusion.

Which of the following is most appropriate management?

A.     Emergency Cardiac Surgery

B.     Emergency Pericardiocentesis

C.     PCI to LAD

D.     Right Heart Cath and Dopamine Infusion

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Kavya Patel MD; Saint Peter's University Hospital, Internal Medicine- Resident PGY-2

Kartik Kalra MD; Saint Peter's University Hospital, Internal Medicine- Resident PGY-2 – Corresponding author

Osakpolor Ogbebor MD MPH MRCP(UK); Saint Peter's University Hospital, Internal Medicine- Resident PGY-1

Damodar Penigalapati MD; Saint Peter's University Hospital, Internal Medicine- Chief Resident