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CASE REPORT

CLINICAL CASE

Acute Myocardial InfarctionWith Cardiogenic Shock Due toPericardial Constriction and MultivesselCoronary Obstruction

Matthew F. Schaikewitz, MD,a Christopher B. Nnaoma, MD,b Richard D. Meredith, MD,c Seth Uretsky, MD,a

Lawrence R. Blitz, MD,a Allan L. Klein, MD,c Mark S. Rosenthal, MDa

ABSTRACT

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We present a rare case of cardiogenic shock and multivessel coronary compression due to focal pericardial inflammation

and constriction. The patient was treated in the acute phase with coronary stenting and temporary mechanical support.

Multimodality imaging was essential in elucidating the diagnosis. (Level of Difficulty: Beginner.)

(J Am Coll Cardiol Case Rep 2020;-:-–-) © 2020 The Authors. Published by Elsevier on behalf of the

American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

A 62-year-old woman awoke from sleep withacute-onset chest pressure. In the emergencydepartment, her blood pressure was 83/

63 mm Hg, and an electrocardiogram (ECG) showedST-segment elevation consistent with an infero-posterolateral myocardial infarction (Figure 1).

LEARNING OBJECTIVES

� To learn about the entity of coronarycompression due to focal pericardialconstriction and fibrous bands.

� To learn the role of multimodality imaging indiagnostic dilemmas.

� To understand a potential late complicationof pericarditis treated with partialpericardiectomy.

N 2666-0849

m the aDepartment of Cardiovascular Medicine, Gagnon Cardiovascular I

stem, Morristown, New Jersey; bDepartment of Internal Medicine, NewarkcDepartment of Cardiovascular Medicine, Cleveland Clinic Foundation, C

ve no relationships relevant to the contents of this paper to disclose.

e authors attest they are in compliance with human studies committe

titutions and Food and Drug Administration guidelines, including patien

it the JACC: Case Reports author instructions page.

nuscript received November 7, 2019; revised manuscript received April 2

PAST MEDICAL HISTORY

There was history of rheumatoid arthritis and anepisode of pericarditis 4 years prior, with pericardialtamponade requiring a pericardial window. Therewere no coronary artery disease risk factors.

DIFFERENTIAL DIAGNOSIS

Because of diffuse ST-segment elevations on the ECGand shock, the patient was brought emergently to thecardiac catheterization lab.

INVESTIGATIONS

Coronary angiography revealed acute total and sub-total occlusions of the left anterior descending artery,first diagonal, and 3 obtuse circumflex branches

https://doi.org/10.1016/j.jaccas.2020.05.031

nstitute, Morristown Medical Center/Atlantic Health

Beth Israel Medical Center, Newark, New Jersey; and

leveland, Ohio. The authors have reported that they

es and animal welfare regulations of the authors’

t consent where appropriate. For more information,

5, 2020, accepted May 6, 2020.

FIGUR

Poster

ABBR EV I A T I ON S

AND ACRONYMS

ECG = electrocardiogram

LAD = left anterior descending

artery

MRI = magnetic resonance

imaging

OM = obtuse marginal

Schaikewitz et al. J A C C : C A S E R E P O R T S , V O L . - , N O . - , 2 0 2 0

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(Central Illustration). The coronary occlusionswere in the mid to distal portions of eachvessel, linearly at nearly identical distancesfrom the left main. There was no evidence ofthrombus or of intracoronary plaque. The 5narrowed coronary artery segments resem-bled spasm, yet there was no response tointracoronary nitroglycerin. There was adynamic component to the occlusions with

the disappearance of several coronary artery seg-ments only during systole (Video 1).

MANAGEMENT

Because of cardiogenic shock, a transvalvular leftventricular support device (Impella CP, Abiomed,Danvers, Massachusetts) was placed, and the patientwas intubated. She underwent stenting of the LADand obtuse marginal (OM) 2 and balloon angioplastyof OM1. Stented segments remained patent, but theballooned vessel continued to exhibit dynamic nar-rowing after angioplasty, as did the untreated OM3and diagonal branches.

The patient was transferred to the cardiac careunit, where she was extubated and weaned frommechanical support after 1 day. Twenty-four hourslater, she complained of recurrent chest discomfort,which was associated with new ST-segment eleva-tions. She was taken back for cardiac catheterization

E 1 Presenting Electrocardiogram

olateral and inferior ST-segment elevations on electrocardiograph

and underwent stenting of OM1 (Figure 2), uponwhich her symptoms improved and ST-segmentsnormalized. Left ventriculography demonstratedmild to moderate left ventricular dysfunction withapical and anterolateral akinesis. Peak troponin Ilevel was 8.9 ng/ml.

After stabilization, echocardiogram showed asym-metric pericardial thickening and a wall motion ab-normality in the posterolateral wall (Figure 3).Because of concern that there was extrinsic pericar-dial scarring affecting coronary flow, coronarycomputed tomography angiography was performed,which demonstrated pericardial thickening and cor-onary stents that were bent at acute angles as ifexternally compressed (Figure 4). Cardiac magneticresonance imaging (MRI) demonstrated delayed gad-olinium enhancement of the anterior and lateralpericardium as well as enhancement and edema on T2short tau inversion recovery sequences (Figure 5),which suggests active pericarditis.

DISCUSSION

We identified 2 prior case reports of multivesselcoronary obstruction occurring in the setting ofpericardial calcification. Bhagia et al. (1) described aman with presumed prior tuberculous pericarditiswho later developed unremitting angina from se-vere LAD obstruction caused by focal calcified

y.

CENTRAL ILLUSTRATION Initial Cardiac Catheterization

Schaikewitz, M.F. et al. J Am Coll Cardiol Case Rep. 2020;-(-):-–-.

Simultaneous 5-vessel occlusion demonstrated on cardiac catheterization. From bottom to top: obtuse marginal (OM3), obtuse marginal 2

(OM2), obtuse marginal 1 (OM1); left anterior descending artery (LAD); and first diagonal (DI). Transaortic mechanical support device

(Impella CP, Abiomed) has been placed.

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pericardial constriction. Angina was relieved withpartial pericardiectomy. Similarly, Gaur et al. (2)described a man with chronic rheumatoid arthritiswho developed LAD obstruction secondary to focalcalcific pericardial band and was treated withpercutaneous coronary intervention. In both of

FIGURE 2 Second Cardiac Catheterization for Recurrent

Chest Pain

The second cardiac catheterization performed for recurrent

chest pain: stent placed to OM1 during this procedure.

Narrowing can be seen in the stents to OM1, OM2, and the LAD.

D ¼ diagonal; LAD ¼ left anterior descending artery;

OM ¼ obtuse marginal.

these cases, pericardial calcification was identifiedby chest x-ray or computed tomography scan.

Hsi et al. (3) described a case of multivessel coro-nary constriction due to a focal pericardial band in theabsence of calcification. A woman with prior pericar-dial window for pericardial effusion due to chest walltrauma from basketball developed cardiac arrest andmultivessel myocardial infarction. The obstructionsall occurred in a linear pattern as if constrictedexternally by a fibrous band. All vessels demonstrated

FIGURE 3 Short-Axis View on Echocardiogram

Asymmetric pericardial thickening seen on echocardiogram.

Large pleural effusion is demonstrated.

FIGURE 4 3-Dimensional Reconstruction From Cardiac Computed Tomography

Cardiac computed tomography demonstrates inward kinking of stents. Abbreviations as in Figure 2.

FIGURE 5 Magnet

(A) The arrows point

confirms that the en

findings are consiste

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Thrombolysis In Myocardial Infarction flow grade 3,so the patient underwent multimodality imagingbefore coronary stenting to determine the etiology ofthe occlusions.

We describe, to our knowledge, the first case ofcardiogenic shock and multivessel infarctionrequiring emergent percutaneous coronary interven-tion and advanced mechanical support due to pre-sumed noncalcified pericardial thickening andtethering with secondary coronary compression. Wesuspect that the initial trigger may have been recur-rent but asymptomatic pericardial inflammation, as

ic Resonance Imaging Sequences Demonstrating Active Pericarditis and Po

to delayed gadolinium enhancement of both the parietal and visceral pericar

hancement is not due to pericardial fat. (C) The arrow points to pericardial e

nt with active pericardial inflammation and possible scarring.

demonstrated on subsequent MRI, along with pre-existing extensive pericardial scarring and adher-ence to the epicardium. We speculate that thisinflammation formed a pericardial band that wascapable of generating enough force to compressmultiple coronary arteries and stents. Because ofintermittent coronary compression and immediateintervention, the infarction size was small, withrelatively low troponin levels and absence of sub-endocardial enhancement on MRI. Interestingly, inthe case of focal pericardial constriction described byBhagia et al. (1), coronary compression was also

ssible Scar

dium. (B) The late gadolinium sequence with fat suppression, which

nhancement on the T2 short tau inversion recovery sequence. The

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intermittent and occurred only during systole, as inour case.

FOLLOW-UP

The patient remained chest pain free after stentingand was discharged home with colchicine, dual anti-platelet therapy, angiotensin-converting enzyme in-hibitor, and beta blocker. She remained chest painfree at the 2-month follow-up. Her rheumatologisthas added a nonsteroidal anti-inflammatory medica-tion to treat the pericarditis. Follow-up echocardiog-raphy showed normalization of left ventricularsystolic function.

CONCLUSIONS

Focal pericardial constriction and coronarycompression is a rare cause of acute multivesselmyocardial infarction and cardiogenic shock. Mul-timodality imaging is helpful in the diagnosis ofthis entity.

ADDRESS FOR CORRESPONDENCE: Dr. Matthew F.Schaikewitz, Department of Cardiovascular Medicine,Gagnon Administration, Davino B, Morristown Medi-cal Center/Atlantic Health System, 100 MadisonAvenue, Morristown, New Jersey 07960. E-mail:matthew.schaikewitz@atlantichealth.org.

RE F E RENCE S

1. Bhagia ST, Patel AR, Reul GJ. Coronaryobstruction by a calcific pericardial ring. AnnThorac Surg 2002;74:595–7.

2. Gaur S, Møller Jensen J, Terkelsen CJ,Ramsing Holm N, Nørgaard BL. Entrapment ofthe left anterior descending coronary artery bylocalized calcific pericarditis. Circulation 2013;128(3):e30–1.

3. Hsi DH, McGrath LB, Salamat J, Simon M,George JC. Epicardial coronary artery compressionsecondary to pericardial adhesions demonstratedby multi-modality imaging, and treated by coro-nary stenting. Circulation 2014;130:e129–30.

KEY WORDS 3-dimensional imaging, acutecoronary syndrome, cardiac assist devices,

computed tomography, echocardiography,MR sequences, percutaneous coronaryintervention

APPENDIX For supplemental videos,please see the online version of this paper.