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This minireview describes 6 previously reported patients with left ventricular free wall rupture and/or aneurysm complicating acute myocardial infarction (AMI) in patients with aortic stenosis. The findings suggest that left ventricular rupture and/or aneurysm is more frequent in patients with AMI associated with aortic stenosis than in patients with AMI unassociated with aortic stenosis, presumably because of retained elevation of the left ventricular peak systolic pressure after the appearance of the AMI.
In 1983, one of us (WCR) reported a patient with severe aortic stenosis (AS) and a healed left ventricular (LV) apical aneurysm (1). The authors speculated that LV aneurysm and LV free wall rupture would be more frequent in patients with acute myocardial infarction (AMI) associated with severe AS than in patients with AMI without AS. Herein, we summarize findings in 5 subsequently reported patients with LV rupture and/or aneurysm with AMI associated with severe AS.
An initial PubMed search was conducted to locate publications of “cardiac rupture or aneurysm in patients with acute myocardial infarction complicated by aortic stenosis.” A second search was made for publications of “myocardial infarction in patients with aortic stenosis.”
Since the report by Roberts and colleagues (1) in 1983, we found 5 additional case reports of patients with AMI complicated by LV free wall rupture and/or aneurysm in patients with AS (2–6). The findings in them are summarized in the Table 1, which also includes the initial report by Roberts et al (1). No reported cases were found in the search for AMI associated with AS irrespective of whether an LV free wall rupture and/or aneurysm was present. At the time of AMI, the 6 patients ranged in age from 57 to 74 years (mean 64); 4 were women and 2 were men. The rupture site in all patients was the LV free wall, leading to hemopericardium. The interval from onset of AMI to rupture ranged from 1 to possibly 30 days. The AS appeared to be severe in all patients: the peak LV systolic gradients (reported in 4 patients) ranged from 50 to 177 mm Hg.
When AMI occurs in patients with systemic hypertension, the systemic arterial and LV pressures generally return to or toward normal if the AMI is fairly large. Several reports have demonstrated that systemic hypertension unassociated with AS in patients with AMI is not a risk factor for LV free wall rupture and/or aneurysm formation (2, 3). When AMI occurs in patients with significant AS, however, the LV systolic pressure remains elevated and the continuation of this elevation appears to increase the likelihood of LV rupture and/or aneurysmal formation, particularly when the AMI involves the LV apical wall, which normally is several times thinner than the LV basal wall.
There is some data on the frequency of AS in older populations and on the frequency of AMI and sudden cardiac death among patients with AS. In an autopsy study, Roberts and Shirani (7) found severe AS to be present in 43 (11%) of 391 patients aged 80 to 89 years, in 8 (9%) of 93 patients aged 90 to 99 years, and in 0 of 6 patients aged ≥100 years, or in 51 (10%) of the total 490 patients aged 80 years or over. Of the 490 autopsied patients, 229 (47%) had acute and/or healed myocardial infarcts. Aronow and colleagues (8) studied by echocardiogram 1797 older patients (mean age 82 years) and found AS in 301 (17%)—severe in 40, moderate in 96, and mild in 165. Among their 301 patients with AS, 158 (52%) had had an earlier AMI that healed, and 217 (72%) had a new AMI or died suddenly. There was no mention of LV free wall rupture or LV aneurysm. There have been at least 2 case reports of AMI in patients with AS and normal epicardial coronary arteries (9, 10). Neither had LV free wall rupture or aneurysm.
The major limitation of this minireview is that the number of patients with AMI associated with AS without LV free wall rupture or LV aneurysm is entirely unknown. Conversely, the reported cases of LV free wall rupture and/or aneurysm complicating AMI in patients with AS may represent, of course, the tip of the iceberg.