Well-documented potential cardiovascular complications associated with the use of contrast media include bradycardia, hypotension, arrhythmia, and conduction disturbances. Rupture of the myocardium after acute myocardial infarction is a known cause of death, but has yet to be recognised as a potential complication of the use of a bolus injection of contrast medium. On the contrary, contrast-enhanced computed tomographic studies have been performed widely for the diagnosis and evaluation of myocardial infarction. We report a case of complicated myocardial rupture after a single bolus injection of contrast medium during a computed tomographic study in an elderly woman with acute myocardial infarction, which led to cardiac tamponade and rapid death. Although rare, this should alert us to the need for cautious use of contrast medium in patients with acute myocardial infarction.published_or_final_versio

Chan, WC

Hau, KC

Lai, V

Lau, HY

Hong Kong Medical Journal

HKU Scholars Hub

TitleMyocardial rupture associated with bolus injection of contrastmedium during computed tomographic study in a patient withacute myocardial infarction: A rare but lethal complicationAuthor(s) Lai, V; Hau, KC; Lau, HY; Chan, WCCitation Hong Kong Medical Journal, 2009, v. 15 n. 4, p. 285-287Issued Date 2009URL http://hdl.handle.net/10722/144252Rights Creative Commons: Attribution 3.0 Hong Kong License	 Hong	Kong	Med	J		Vol	15	No	4	#	August	2009	#		www.hkmj.org	 285IntroductionContrast-enhanced computed tomographic (CT) scans are being performed daily for many reasons. They are especially useful for the evaluation of patients with acute chest symptoms because myocardial infarction, pulmonary embolism, and aortic dissection have overlapping clinical presentations. Indeed, advances in technology and the introduction of multidetector CT scan have enabled better evaluation of the heart. Yet, the potential risks to the cardiovascular system of using a bolus injection of contrast medium, although rare, should not be ignored or underrated. Here, we report a rare case of complicated left ventricular free wall rupture after a single bolus injection of contrast medium during a CT study in an elderly woman with acute myocardial infarction. Such a case has not been reported in the literature to date. This should alert us to the potential, if rare, complications that use of a bolus injection of contrast medium may induce, and lead to more cautious use of contrast medium in the future.Case reportAn 85-year-old woman, with a history of good past health, was admitted to hospital for right lower abdominal pain. The abdominal pain was mild and she did not require any analgesia. On physical examination, she had a low-grade fever but was otherwise stable with normal vital signs. Her blood pressure remained within normal limits (systolic pressure: 130 mm Hg and diastolic pressure: 55 mm Hg). On abdominal palpation, mild tenderness was elicited in the right lower quadrant. Her initial blood tests (a full blood count, liver and renal function tests, and a serum amylase level) were unremarkable. A provisional diagnosis of diverticulitis or early appendicitis was made and she was treated with intravenous antibiotics. Two days later, her abdominal discomfort persisted despite resolution of her fever, so an urgent CT scan of the abdomen and pelvis was arranged to seek the underlying cause. While awaiting the CT scan, a repeated blood screen was performed and revealed elevated cardiac enzymes, with a creatine kinase level of 211 U/L (reference range, 42-190 U/L) and lactate dehydrogenase level of 477 U/L (211-370 U/L). Her serum troponin I level was also elevated at 3.7 ng/mL (reference level, <0.060 ng/mL). An electrocardiogram was performed and showed ST segment elevation and T wave inversion in the anterolateral leads, confirming an acute myocardial infarction. The patient was then sent for an urgent CT study. She remained well during the initial non-contrast scanning period but developed a sudden cardiac arrest immediately after an intravenous bolus injection of 80 mL non-ionic water-soluble contrast at a rate of 3 mL/sec during the contrast-scanning phase. Resuscitation commenced at once. A review of the Myocardial rupture associated with bolus injection of contrast medium during computed tomographic study in a patient with acute myocardial infarction: a rare but lethal complicationC A S ER E P O R TKey wordsContrast media; Heart rupture, post-infarction; Injections, intra-arterial; Tomography, X-ray computedHong Kong Med J 2009;15:285-7Tuen Mun Hospital, Tuen Mun, Hong Kong:Department of RadiologyV Lai, MB, ChB, FRCRHY Lau, MB, ChBWC Chan, MB, ChBDepartment of Medicine and GeriatricsKC Hau, MB, ChB, MRCPCorrespondence to: Dr V LaiE-mail: vincentlai@hkcr.orgVincent LaiKC HauHY LauWC Chan黎永信侯佳禎劉顯宇陳允芝Well-documented potential cardiovascular complications associated with the use of contrast media include bradycardia, hypotension, arrhythmia, and conduction disturbances. Rupture of the myocardium after acute myocardial infarction is a known cause of death, but has yet to be recognised as a potential complication of the use of a bolus injection of contrast medium. On the contrary, contrast-enhanced computed tomographic studies have been performed widely for the diagnosis and evaluation of myocardial infarction. We report a case of complicated myocardial rupture after a single bolus injection of contrast medium during a computed tomographic study in an elderly woman with acute myocardial infarction, which led to cardiac tamponade and rapid death. Although rare, this should alert us to the need for cautious use of contrast medium in patients with acute myocardial infarction.		#		Lai	et	al	#286	 Hong	Kong	Med	J		Vol	15	No	4	#	August	2009	#		www.hkmj.org造影劑可能引發的心血管併發症，包括心博過緩、低血壓、心律失常，以及傳導受阻問題，文獻中早有記載。目前已知急性心肌梗塞可引發心肌破裂致死，可是使用團注造影劑而有可能引致心肌破裂這種潛在的併發，則鮮為人知。另一方面，增強掃描被廣泛用作診斷及評估心肌梗塞。本文報告為一名急性心肌梗塞的年長女病人進行電腦掃描時，因團注造影劑引致心肌破裂，最後病人因心臟壓塞而快速死亡的病例。此病例雖然罕見，卻提醒我們對急性心肌梗塞病人使用造影劑時要格外小心。為急性心肌梗塞病人進行電腦掃描時與團注造影劑有關的心肌破裂：一種罕見但會引致死亡的併發症images showed that caecal diverticulitis accounted for the patient’s symptoms. The major concern, however, was the normal-looking myocardium and pericardium seen during the non-contrast phase (Fig 1) complicated by rupture of the left ventricular free wall with active contrast extravasation (Fig 2a) and haemopericardium (Fig 2b) during the contrast phase. Such dramatically different findings indicated that the bolus contrast injection induced myocardial rupture. Because the patient had developed cardiac tamponade, an urgent ultrasound-guided pericardiocentesis was performed and fresh blood was drained out. She did not respond to resuscitation, however, and finally died 1 hour afterward.DiscussionMyocardial rupture is commonly divided into three FIG 1. Non-contrast computed tomographic scan showing normal-looking heart and pericardium(a)(b)FIG 2. Post-contrast computed tomographic scans (a) revealing ruptured left ventricular free wall with active contrast extravasation, and (b) showing contrast collection in the pericardium with cardiac tamponademajor subgroups: rupture of the papillary muscle, the interventricular septum, and the free wall. Acute rupture of the free wall is the most common type of rupture, comprising more than 50% of all ruptures,1 and accounts for 10% of in-hospital deaths following acute myocardial infarction.2 Rupture of the papillary muscle and interventricular septum are less frequent, accounting for 8% and 16% respectively. Being female, having hypertension, diabetes, angina, and previous myocardial infarction are all risk factors for ruptured myocardial death, with prolonged and recurrent chest pain being the most frequent and consistent clinical characteristic.1 Myocardial rupture usually occurs between 3 and 6 days or within 2 weeks after the infarction,3 typically #		Myocardial	rupture		# 	 Hong	Kong	Med	J		Vol	15	No	4	#	August	2009	#		www.hkmj.org	 2871.	 Dellborg	 M,	 Held	 P,	 Swedberg	 K,	 Vedin	 A.	 Rupture	 of	the	myocardium.	Occurrence	 and	 risk	 factors.	 Br	 Heart	 J	1985;54:11-6.2.	 Trindade	ML,	Tsutsui	JM,	Rodrigues	AC,	Caldas	MA,	Ramires	JA,	Mathias	 Junior	W.	 Left	 ventricular	 free	 wall	 impeding	rupture	 in	 post-myocardial	 infarction	 period	 diagnosed	by	 myocardial	 contrast	 echocardiography:	 case	 report.	Cardiovasc	Ultrasound	2006;4:7.3.	 Lewis	 AJ,	 Burchell	 HB,	 Titus	 JL.	 Clinical	 and	 pathologic	features	 of	 postinfarction	 cardiac	 rupture.	 Am	 J	 Cardiol	1969;23:43-53.4.	 Gosalia	 A,	 Haramati	 LB,	 Sheth	 MP,	 Spindola-Franco	 H.	CT	 detection	 of	 acute	 myocardial	 infarction.	 AJR	 Am	 J	Roentgenol	2004;182:1563-6.5.	 Karliner	JS,	Bouchard	RJ,	Gault	JH.	Haemodynamic	effects	of	 angiographic	 contrast	 material	 in	 man.	A	 beat-by-beat	analysis.	Br	Heart	J	1972;34:347-55.6.	 Higgins	CB,	Gerber	KH,	Mattrey	RF,	Slutsky	RA.	Evaluation	of	 the	 hemodynamic	 effects	 of	 intravenous	 administration	of	 ionic	 and	 nonionic	 contrast	 materials.	 Implications	for	 deriving	 physiologic	 measurements	 from	 computed	tomography	and	digital	cardiovascular	 imaging.	Radiology	1982;142:681-6.7.	 Popovic	AD.	Old	and	new	paradigms	on	diastolic	function	in	acute	myocardial	infarction.	Am	Heart	J	1999;138:S84-8.8.	 Bashour	T,	 Kabbani	 SS,	 Ellertson	 DG,	 Crew	 J,	 Hanna	 ES.	Surgical	 salvage	of	 heart	 rupture:	 report	 of	 two	cases	 and	review	of	the	literature.	Ann	Thorac	Surg	1983;36:209-13.9.	 Lillehei	CW,	Lande	AJ,	Rassman	WR,	Tanaka	S,	Bloch	 JH.	Surgical	management	of	myocardial	infarction.	Circulation	1969:39(Suppl	IV):315S-333S.10.	Cobbs	BW	Jr,	Hatcher	CR	Jr,	Robinson	PH.	Cardiac	rupture.	Three	 operations	 with	 two	 long-term	 survivals.	 JAMA	1973;223:532-5.Referencesinvolving the anterior or lateral wall, in the terminal region of the left anterior descending coronary artery distribution.2 Rupture of the left ventricular free wall usually leads to haemopericardium and death from cardiac tamponade, which can be acute (acute tear leading to immediate death) or subacute (slow and incomplete tear leading to late rupture). Non-ionic water-soluble iodinated contrast is the agent of choice for performing contrast CT studies. Iodinated contrast medium can cause a wide range of complications. Well-documented potential cardiovascular complications include hypotension, bradycardia, arrhythmias and conduction disturbances, probably via vasovagal reactions, a direct negative inotropic effect on the myocardium and peripheral vasodilatation. Our case has demonstrated that a single bolus injection of contrast medium can induce myocardial rupture in patients with acute myocardial infarction, which, to the best of our knowledge, has not been reported in the literature to date. It is difficult to be certain of the pathogenesis, especially when there have been a significant number of past studies using CT to evaluate acute myocardial infarction or ruptured myocardium using contrast-enhanced CT scans,4 and contrast is routinely used during cardiac catheterization for patients suffering from myocardial infarction. We postulate that the large volume of contrast injected at a rapid rate via the mechanical power injector may have generated a pressure with each stroke volume that was too high for the infarcted myocardial tissue to withstand, leading to perforation. Previous studies in experimental animals have shown that cardiac output elevation occurs as early as 3 seconds after the injection of a volume load.5 A similar phenomenon can be observed in humans when intravenous iohexol is injected, resulting in a statistically significant increase in the left ventricular systolic pressure and left ventricular diastolic diameter as early as 15 seconds after injection.6 This phenomenon would be exaggerated in myocardial infarction as left ventricular stiffness increases after infarction.7 Therefore, a single bolus injection of contrast can increase left ventricular pressure to a degree theoretically able to rupture infarcted myocardium. This single report raises the possibility of this rare complication of use of contrast-medium injection during a CT study and should warn us to use it cautiously in patients with acute myocardial infarction. Although successful surgical intervention using rapid pericardiocentesis, volume expansion and immediate surgery using cardiopulmonary bypass has been reported,8-10 treatment should be directed towards prevention of rupture due to its lethal nature. Therefore, the potential risks of intravascular administration of contrast medium must be weighed against the potential benefits and thoroughly discussed with the patient beforehand. It is important to identify individuals for whom there is an increased risk of such an adverse event and to search for an alternative investigative modality where necessary.

Myocardial rupture associated with bolus injection of contrast medium during computed tomographic study in a patient with acute myocardial infarction: A rare but lethal complication

http://hub.hku.hk/bitstream/10722/144252/2/Content.pdf

Myocardial rupture associated with bolus injection of contrast medium during computed tomographic study in a patient with acute myocardial infarction: A rare but lethal complication

Abstract

Similar works

Full text

Available Versions

HKU Scholars Hub