“Tear in My Heart”: A Multimodality Perspective
Bibliographic record
Abstract
A 72-year-old woman presented with a late-presenting inferior ST-segment elevation myocardial infarction (Fig. 1A ). Coronary angiography demonstrated a culprit lesion of the distal right coronary artery treated with 2 drug-eluting stents (Fig. 1B; Video 1 , view video online). A left ventriculogram demonstrated inferior wall hypokinesis and a sliver of contrast within the pericardium along the inferior wall with no obvious ventricular septal defect. Repeated injections into the coronary circulation revealed no evidence of contrast-dye extravasation. An urgent point-of-care ultrasound revealed a trivial pericardial effusion. An electrocardiogram-gated computed tomography (CT) scan of the heart within 30 minutes of the primary percutaneous coronary intervention confirmed that the pericardial effusion progressed to a moderate-sized hemopericardium with extravasation of contrast from the inferolateral wall of the left ventricle (Fig. 1C). Transthoracic echocardiography with left ventricular opacification following administration of Definity (Perflutren lipid microsphere [Lantheus, Billerica, MA]) demonstrated microbubbles within the pericardial space, confirming the free-wall rupture (Fig. 1D; Video 2 , view video online). The patient underwent emergency cardiac surgery; intraoperatively, a punctate inferolateral free-wall tear of the left ventricle was identified and repaired with a bovine pericardial patch (Fig. 1E; Video 3 , view video online). Mechanical complications following an acute myocardial infarction are exceedingly rare in the era of primary percutaneous coronary intervention, occurring in less than 1% of acute coronary syndrome presentations.1French J.K. Hellkamp A.S. Armstrong P.W. et al.Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction.Am J Cardiol. 2010; 105: 59-63Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar,2Elbadawi A. Elgendy I.Y. Mahmoud K. et al.Temporal trends and outcomes of mechanical complications in patients with acute myocardial infarction.JACC Cardiovasc Interv. 2019; 12: 1825-1836Crossref PubMed Scopus (65) Google Scholar However, ventricular free-wall rupture is the most common complication with late-presenting ST-segment elevation myocardial infarction, with the right coronary artery being the least likely culprit vessel, accounting for only 23% of cases.3Massad M.G. Geha A.S. Surgical repair of mechanical complications of myocardial infarction.World J Surg. 2004; 28: 847-856Crossref PubMed Scopus (5) Google Scholar Although there are few case reports of survival following a conservative approach, surgical repair is the treatment of choice.3Massad M.G. Geha A.S. Surgical repair of mechanical complications of myocardial infarction.World J Surg. 2004; 28: 847-856Crossref PubMed Scopus (5) Google Scholar,4Reardon M. Carr C. Diamond A. et al.Ischemic left ventricular free wall rupture: prediction, diagnosis, and treatment.Ann Thorac Surg. 1997; 64: 1509-1513Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Surgical intervention alleviates the life-threatening pericardial tamponade and closes the ventricular free-wall tear. When a new pericardial effusion is identified in the acute coronary syndrome setting, prompt diagnosis of a ventricular free-wall rupture with multimodality cardiovascular imaging using CT and contrast echocardiography should be pursued.Novel Teaching Point•When a new pericardial effusion is identified in the post–myocardial infarction setting, prompt diagnosis of a ventricular free-wall rupture with multimodality cardiovascular imaging using CT and contrast echocardiography should be pursued. •When a new pericardial effusion is identified in the post–myocardial infarction setting, prompt diagnosis of a ventricular free-wall rupture with multimodality cardiovascular imaging using CT and contrast echocardiography should be pursued. The authors have no funding sources to declare.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".