Journal Article

Left ventricular dissecting haematoma and aneurysm formation in a patient who uses methamphetamines: a case report

Ruwanpathirana, Pramith, Poornima, Subhani, Dissanayake, Gayan, Galappaththi, Gamini, Amaratunga, Disna

2024

Overview

Introduction Myocardial dissection is a rare complication of ischaemic heart disease. It occurs when a haematoma forms within the cardiac muscle, either due to an endocardial rupture or rupture of an intra-myocardial vessel. Higher ventricular wall tension and reduced myocardial tensile strength increase the risk of dissection. We describe a young male who developed a myocardial dissection following an ST elevation infarction. We explore the possible pathophysiological connection between myocardial dissection and his amphetamine use. Case presentation A 37-year-old Sri Lankan patient presented with progressively worsening heart failure for two weeks. One month before the presentation, he had developed an ischaemic chest pain, for which he had not sought medical advice. He was abusing inhalational heroin, crystal methamphetamines and cigarette smoke daily for five years. On examination, the patient had a blood pressure of 90/60 mmHg and a pulse rate of 110 beats per minute. The cardiac apex was deviated. The jugular venous pressure was elevated, bilateral pitting ankle and pulmonary oedema were present. The ECG had Q-ST elevations in the lateral leads. Serum troponin was elevated. A transthoracic echocardiogram revealed a poorly functioning dilated left ventricle with a mass within the myocardial apex. Cardiac MRI established that the mass was an intra-myocardial haematoma. A coronary angiogram demonstrated a critical plaque stenosis at the mid left-anterior-descending artery with poor distal flow. The patient did not have HIV or infective endocarditis. We treated the patient with diuretics and guideline-directed medical therapy for heart failure with reduced ejection fraction. We did not attempt surgical repair as the dissection was non-expanding, and the patient was at a high risk of operative complications. Conclusions Myocardial dissection with aneurysm formation is a rare complication of ischaemic heart disease. Methamphetamines enhance the risk of myocardial dissection by inducing myocardial inflammation, causing a dilated cardiomyopathy and increasing the left ventricular pressures.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Acute coronary syndromes / Adult / Amphetamine-Related Disorders - complications / Amphetamine-Related Disorders - diagnosis / Amphetamine-Related Disorders - physiopathology / Amphetamines / Analysis / Aneurysm / Aneurysms / Angiology / Ankle / Aortic Dissection - chemically induced / Aortic Dissection - diagnostic imaging / Aortic Dissection - surgery / Blood pressure / Blood Transfusion Medicine / Cardiac muscle / Cardiac Surgery / Cardiology / Cardiomyopathy / Cardiovascular disease / Care and treatment / Case Report / Central Nervous System Stimulants - adverse effects / Cigarette smoke / Complications and side effects / Congestive heart failure / Coronary Angiography / Coronary artery disease / Coronary vessels / Development and progression / Dilated cardiomyopathy / Dissection / Diuretics / Dosage and administration / Dyspnea / Echocardiography / Edema / EKG / Electrocardiogram / Electrocardiography / Endocarditis / Haematoma / Health aspects / Heart Aneurysm - chemically induced / Heart Aneurysm - diagnostic imaging / Heart Aneurysm - etiology / Heart Aneurysm - physiopathology / Heart attacks / Heart failure / Heart rate / Hematoma / Hematoma - chemically induced / Hematoma - diagnostic imaging / Hematoma - etiology / Heroin / Humans / Hypertension / Infarction / Internal Medicine / Ischemia / Magnetic resonance imaging / Male / Medicine / Medicine & Public Health / Methamphetamine / Methamphetamine - adverse effects / Myocardial dissection / Pericardium / Pseudoaneurysm / Rare diseases / Smoking / ST Elevation Myocardial Infarction - diagnosis / ST Elevation Myocardial Infarction - etiology / ST Elevation Myocardial Infarction - physiopathology / STEMI / Stenosis / Troponin / Ultrasonic imaging / Ventricle