The Herniated Heart: A Rare Cause of Myocardial Infarction Identified by Multimodality Imaging

Figure 1. Single-view anteroposterior chest radiograph demonstrates diffuse bilaterial interstitial and alveolar opacities consistent with pulmonary edema.

Figure 2. ICA, right anterior oblique cranial projection, demonstrates linear compression of coronary arteries during diastole (A) and normal-caliber coronary arteries with minimal filling defects in systole (B).

Figure 3. (A) Index hospitalization two-dimensional (2D) TTE, apical four-chamber view (left ventricle [LV] on right), demonstrates a thickened and poorly delineated anterolateral wall (arrows) in systole. (B) Repeat 2D TTE, zoomed-in apical four-chamber view (LV on left), demonstrates bulging of the thickened anterolateral ventricular wall beyond an area of constriction, where the myocardium appeared pinched. RV, Right ventricle.

Figure 4. CCT, multiplanar reconstruction in sagittal (A), axial (B), and oblique coronal (C) views, demonstrates masslike thickening of the lateral, anterolateral, and inferolateral wall (red arrows) and severe focal stent deformation in the first diagonal artery (yellow arrow).

Figure 5. (A) CMR, T2-weighted short-tau inversion recovery short-axis image, demonstrates increased signal throughout the anterior and lateral walls (red arrows), sparing the subendocardium (yellow arrow), consistent with myocardial edema. (B) CMR, LGE sequence using phase-sensitive inversion recovery (PSIR), short-axis image, demonstrates subepicardial enhancement in the same distribution (red arrows) with subendocardial sparing (yellow arrow). (C) CMR, LGE sequence using PSIR, axial view, demonstrates thickening of the lateral wall of the left ventricle with more intense delayed enhancement along the lateral wall at the base and inferolateral mid and apical wall where the myocardium appears pinched, suggesting ring-shaped constriction with associated LGE.

Figure 6. Surgical images at the start of pericardiectomy showing (A) an anterior partial pericardial defect and (B) white strangulated lateral myocardium with linear rim of restricting pericardium.

Figure 7. Postpericardiectomy ICA, right anterior oblique cranial projection, demonstrates stent deformation (A, circle) and results after balloon angioplasty of deformed D1 stent (B). (C) Post-PCI virtual histology intravascular ultrasound display of the left anterior descending coronary artery demonstrates a well-expanded, well-apposed stent (white) with mild atherosclerotic plaque composed predominantly of fibrosis tissue (green) with minimal necrotic core (red).

Figure 8. Proposed clinical algorithm for the diagnosis and management of ventricular herniation presenting as STEMI. ACS, Acute coronary syndrome; ECG, electrocardiography; IVUS, intravascular ultrasound; TIMI, Thrombolysis in Myocardial Infarction.

Figure 9. (A) CMR, axial postcontrast CAIPIRINHA (controlled aliasing in parallel imaging results in higher acceleration)–accelerated VIBE (volumetric interpolated breath-hold examination) with fat suppression in the delayed phase, demonstrates absence of the pericardium (yellow oval) along the lateral wall; remaining pericardium is visualized (red ovals). (B) CMR, short-axis T2-weighted triple inversion recovery sequence in our patient, demonstrates myocardial edema of the herniated wall (red arrows).