ABC | Volume 114, Nº4, Suplement, April 2020

Anatomopathological Correlation Favarato & Benvenuti Heart failure after myocardial infarction an rupture of chordae tendineae Arq Bras Cardiol 2020; 114(4Suppl.1):47-56 hydro-air noises were present; bilateral +++ / 4+ lower- limb edema, with no signs of deep venous thrombosis. Chest radiography (May 21, 2017) showed clear lung fields and cardiomegaly (Figure 6). Laboratory tests showed hemoglobin 8.2 g/dL, hematocrit 25%; leukocytes 22750 / mm³ (94% neutrophils, 3% lymphocytes, 3% monocytes), platelets 217000 / mm³; urea 147 mg / dL, creatinine 3.21 mg / dL, C-Reactive Protein 49.19 mg / L; sodium 133 mEq / L and potassium 3.7 mEq / L; lactate 34 mg / dL. She had a seizure episode and received phenytoin. There was asystole which did not respond to resuscitation maneuvers and she died at 10:55 pm on May 21, 2017. Clinical aspects A 55-year-old patient with arterial hypertension and heart failure for one year and with chest pain, had a cardiorespiratory arrest five months before, developed heart failure and mitral regurgitation due to mitral valve prolapse and rupture of chordae tendineae. The diagnostic impression is that heart failure due to mitral valve disease preceded the episode of precordial pain and severe dyspnea. As for the episode of precordial pain, it is discussed whether it was really a myocardial infarction or an episode of rupture of chordae tendineae with a sudden worsening of mitral regurgitation and acute pulmonary edema. The most recent classification of myocardial infarction (the fourth universal definition) introduced a new concept – “myocardial injury” (myocardial injury without infarction) in which there is an elevation of the lesion marker (troponin level), however without constituting an infarction due to the concomitant absence of suggestive clinical picture and electrocardiographic and wall motility alterations. This situation can be found in a large number of clinical conditions – anemia, ventricular tachycardia, heart failure, kidney disease, hypotension and shock, hypoxemia. The new definition included two types of myocardial injury: the acute one with troponin curve, elevation and fall, and the chronic one, with sustained elevation of troponin. 1 In the same publication it can be noted that there is a continuum between the “isolated myocardial injury” and type 2 infarction, as the conditions that originate them are the same, depending only on the intensity and occurrence of electrocardiographic and echocardiographic alterations and a clinical picture compatible with the diagnosis of infarction. In this sense, there is a case report of a patient who sought the Emergency Services for abdominal discomfort and severe dyspnea. The condition was preceded by chest pain 24 hours before the event. The patient already had a previous diagnosis of mitral valve prolapse. There was an increase in troponin levels and nonspecific alterations in ventricular repolarization. The echocardiogram showed severe mitral regurgitation, rupture of chordae tendineae and severe prolapse of half of the posterior cusp. Unlike the Figure 6 - Chest radiography (May 21, 2017) showing clear lungs and cardiomegaly. 51