Extract

Case report

An 82-year-old woman was admitted to our hospital with a 9-day history of intermittent chest pain. Electrocardiography showed abnormal Q waves in leads II, III, and aVF and ST-segment elevation in leads II, III, aVF, V4, V5, and V6 (Panel A). Echocardiography showed not only inferoposterior wall akinesis but also an intramyocardial tunnel in the posterior wall, where a turbulent systolic jet entered from the left ventricular (LV) endocardium and exited to the right ventricular (RV) cavity. Notably, the interventricular communication was found via the intramyocardial tunnel of the posterior wall but not via the ventricular septum (Panel B; see Supplementary Data). Right coronary angiography demonstrated mid-vessel occlusion without collateral supply (see Supplementary Data). On enhanced computed tomography and left ventriculography, we found the intramyocardial tunnel at the mid-ventricular level (Panels C and D, white arrows) and subsequent enhancement of RV cavity (red and blue arrows indicate the beginning and ending of the tunnel, respectively). Emergent surgical repair was planned; however, her haemodynamics progressively deteriorated, resulting in death, despite intensive treatment including percutaneous coronary intervention, intra-aortic balloon pumping, and maximum inotropic support. An autopsy confirmed that the intramyocardial tunnel (white arrows) in the mid-myocardium bridged LV and RV with an unruptured ventricular septum (Panels E and F).

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