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Jefferson Cardiologists Fix Broken Heart

Case study points out rarely diagnosed, potentially fatal complication of heart attack

In a case study published in the January issue of the international journal Clinical Cardiology, physicians at Thomas Jefferson University Hospital in Philadelphia report on a rare but potentially fatal condition in which patients have impending rupture of the heart. The physicians describe the case of a seemingly healthy 55-year-old man who had sudden, unexplained chest pain.

Once this patient was admitted to Jefferson Hospital, examining physicians diagnosed that the man had recently suffered a “silent” heart attack and, as a result, developed a rarely diagnosed complication called subepicardial aneurysm. This is an impending rupture of the heart wall that, if not treated quickly, could be fatal.

“The chest pain was a rupture of the heart wall about to happen, which is the most feared complication of a heart attack,” explains Michael P. Savage, MD, Director of the Cardiac Catheterization Laboratory at Thomas Jefferson University Hospital. “The rupture occurs from a tear in the muscle that has already been damaged by a heart attack. The heart muscle breaks and the wall bursts, usually causing cataclysmic death soon after.”

Rarely diagnosed – but not necessarily rare – condition
Diagnosis of subepicardial aneurysm is extremely rare, says Dr. Savage, who is also Associate Professor of Medicine, Jefferson Medical College (JMC) of Thomas Jefferson University. Only 20 cases have ever been reported in the medical literature, and many of those cases were not diagnosed until after the patients had died.

But, although rarely diagnosed, the condition itself is not necessarily rare. It is likely that many more patients have died from subepicardial aneurysm but that this cause of death was unrecognized.

“The probable reason that it’s not often caught,” explains Aaron Giltner, MD, a cardiology fellow at Thomas Jefferson University Hospital, “is that the rupture may only last in its incomplete state for a brief period before it explodes, and the associated pain may be mistakenly attributed to coronary artery blockage.”

Case study
The newly published case study, for which Dr. Giltner was the lead investigator, centers on a construction worker who came to Jefferson Hospital’s Emergency and Trauma Center in April 2005 complaining of chest pain. The emergency medicine physicians who originally saw the patient initially considered his chest pain to be a heart attack and brought in Jefferson cardiologists for a consult.

The cardiologists also initially suspected a heart attack. The patient then underwent a cardiac catheterization, where contrast dye is injected to check for blocked arteries and to assess the function of the heart’s main pumping chamber, the left ventricle. The dye revealed that blood was not flowing in a normal pattern from the left ventricle of the patient’s heart and suggested the possibility that the pain felt by the patient was caused not by a heart attack but by a tear in the heart wall and an impending cardiac rupture.

The physicians then arranged with Jefferson’s radiology team for the patient immediately to undergo computed tomographic angiography (CTA), a non-invasive cardiac imaging procedure, the high-resolution images from which can reveal soft tissue structures not shown by normal X-rays and determine if a patient’s chest pain is actually due to a heart attack or something else. (Jefferson’s Department of Emergency Medicine is – unlike any other in Philadelphia –equipped with the 64-slice CT scanner necessary for this procedure, which must be conducted as quickly as possible, as the fatal rupture can occur at any time.) The superior images supplied by the CT scan confirmed that the patient had a subepicardial aneurysm and that his sharp chest pain was actually due to tearing in his heart wall, which, in turn, was initiated by a “silent” heart attack he had unknowingly suffered several days earlier.

“One out of four heart attacks is silent, meaning that the patient doesn’t experience any associated chest pain and, therefore, doesn’t even know that he or she is having a heart attack ,” Dr. Giltner says. “As a result, the heart attack goes untreated, leading to muscle weakening that increases the risk of rupture.”

Once the problem was identified, the Jefferson cardiac surgical team promptly repaired the patient’s partial muscle tear before it actually ruptured, thereby saving his life. The surgery was tricky because the ruptured heart muscle was very damaged so that its normal consistency had given way to a soft, almost boggy tissue (Dr. Savage likens the change in texture to that from steak to raw hamburger). As a result, sewing a patch on the damaged area was difficult – but successful.

The rapid response and team work of Jefferson cardiologists, radiologists and cardiac surgeons led to rapid diagnosis and definitive, successful therapy. Nearly two years later, the patient is doing very well. He’s been unable to resume his manual labor but is able to exercise lightly and otherwise enjoy a normal lifestyle.

CTA imaging can be an invaluable diagnostic tool
“As our study shows,” Dr. Savage says, “CTA imaging can be invaluable in establishing the diagnosis of a subepicardial aneurysm. Clinical recognition of this entity and the use of appropriate imaging modalities are imperative to facilitate life-saving surgical intervention.”

Along with Dr. Giltner and Dr. Savage, other physicians involved with this study include Ethan J. Halpern, MD, MS, Director of the Jefferson Hospital Center for the Advancement of Noninvasive Cardiac Imaging, Vice Chair of Radiology at Jefferson Hospital, Co-director of the Jefferson Prostate Diagnostic Center, and Professor of Radiology and Urology at JMC; and former Jefferson heart surgeon Daniel Marelli, MD.

For information about innovative treatment for cardiac disease or to make an appointment with a Jefferson cardiologist, call 1-800-JEFF-NOW.

Image of left ventricle taken during cardiac catheterization showing subepicardial aneurysm at lower border, as indicted.

Image of left ventricle obtained by CT showing same projection and subepicardial aneurysm, as indicated.