Intramyocardial Dissection with Rupture of the Right Ventricle After an Acute Myocardial Infarction -- A Rare Complication Diagnosed by Transesophageal Echocardiography

A 69-year-old male was admitted to the Emergency Room in cardiogenic shock after complaining of dyspnea and intense precordial pain. The ECG showed Q waves in the inferior leads. Transthoracic echocardiography showed good left ventricular function with akinesis of the basal inferior wall and a small pericardial effusion suspected to be hemorrhagic. A transesophageal echocardiography was performed due to an elevated D-dimer level and a high clinical suspicion of pulmonary embolism. Surprisingly, an intramyocardial channel originating from the akinetic infero-posterior wall of the left ventricle, leading to the right ventricle with intraluminal flow (Fig. 1(a) and (b)) was detected, suggesting a diagnosis of intramyocardial dissection from the left ventricle through the right ventricular wall into the pericardium. The patient was referred for urgent surgery; intra-operatively a huge clot that resembled a ‘placenta’, which covered all the cardiac chambers was found, along with a friable and hemorrhagic zone of the right ventricle with signs of a recent infero-posterior