Cardiac rupture or pericardial effusion?

After cardiogenic shock, myocardial rupture is the leading cause of in-hospital death from acute myocardial infarction (AMI). When possible, rapid diagnosis must lead to an emergency surgical repair to prevent sudden death. However, in some cases, despite new imaging techniques, the diagnosis may be difficult to obtain and the decision whether or not to operate, difficult. In the present report we describe the challenging case of a patient presenting a sub-acute cardiac rupture three days after anterior AMI.     

Unexpected rupture of the left ventricular free wall in the echo-lab

Background: Left ventricular free wall rupture is an uncommon but catastrophicevent following myocardial infarction, and considered the secondleading cause of death in acute myocardial infarct. Differenttypes of rupture exist from acute to sub acute types, but prognosisis usually poor. Early recognition and aggressive treatmentis recommended. Case report: We present a case of a 75-year-old man who was referred to ourecho-lab for an out patient evaluation because of 1-week durationof worsening of chest pain. Standard transthoracic echocardiographyshowed hypokinesia in the apical portion of the anterior walland basal portion of the inferior wall. The patient complainedof shortness of breath immediately after the conclusion of theexam, and soon afterward became unconscious. Renewed echocardiographyapproximately 1 min after syncope displayed a newly developedecho-lucent rim around the heart consistent with left ventricularfree wall rupture. Resuscitation was performed followed by attemptsto evacuate the blood by needle aspiration, which failed. Openpericardiocentesis stabilised the patient until surgery couldbe performed. The patient survived and could be discharged 2weeks later. Conclusion: This case highlights the fact that rapid and accurate diagnosisis essential if patients with left ventricular free wall ruptureare to survive.     

Rupture of the myocardium. Occurrence and risk factors

The occurrence of myocardial rupture was studied in a well defined unselected population of patients with acute myocardial infarction, and the group of patients who died of rupture of the heart were compared with two control groups. Of a total of 3960 patients, 1746 (44%) fulfilled the diagnostic criteria for acute myocardial infarction. Rupture was defined solely on the basis of the presence of a pathological passage through part of the myocardium, either the free wall of the left ventricle or the septum, found at necropsy or during operation. Two controls were selected for each patient and matched for age and sex, one (control group A) with acute myocardial infarction having died in hospital but not of rupture (non-rupture cardiac death) and one (control group B) with acute myocardial infarction having survived the hospital stay. Necropsy was performed in 75% of all fatal cases with acute myocardial infarction. The total hospital mortality was 19%, the highest mortality being among women over 70 years (29%). Ruptures (n = 56) were found in 17% of the hospital deaths, or 3.2% of all cases of acute myocardial infarction. Women aged less than 70 had the highest incidence of rupture, 42% of deaths being due to rupture. The mean age for patients with rupture and controls was 70.5 years. The median time after admission to death was approximately 50 hours for patients and control group A. Thirty per cent of the patients with rupture occurred within 24 hours of the initial symptoms occurring. Angina and previous acute myocardial infarction were more common among control group A. Patients with rupture and control group B were mostly relatively free of previous cardiovascular or other diseases (chronic angina pectoris ( > 2 months) and previous myocardial infarction). Sustained hypertension during admission to the coronary care unit was more common in patients than in control group A. Hypotension and shock were more common among control group A. Most (79%) of the patients who subsequently ruptured did not receive any corticosteroids at all during the hospital stay. Severe heart failure and antiarrhythmic treatment were more uncommon among patients than among control group A. Patients with rupture received analgesics approximately three times a day throughout their stay. Control group B received analgesics mostly during the first 24 hours. Thus female patients, patients with first infarcts, and patients with sustained chest pain should be investigated for the possibility of rupture. As many as one third (32%) of ruptures may be subacute, and therefore time is available for diagnosis and surgery.     

Rupture of the myocardium. Occurrence and risk factors.

The occurrence of myocardial rupture was studied in a well defined unselected population of patients with acute myocardial infarction, and the group of patients who died of rupture of the heart were compared with two control groups. Of a total of 3960 patients, 1746 (44%) fulfilled the diagnostic criteria for acute myocardial infarction. Rupture was defined solely on the basis of the presence of a pathological passage through part of the myocardium, either the free wall of the left ventricle or the septum, found at necropsy or during operation. Two controls were selected for each patient and matched for age and sex, one (control group A) with acute myocardial infarction having died in hospital but not of rupture (non-rupture cardiac death) and one (control group B) with acute myocardial infarction having survived the hospital stay. Necropsy was performed in 75% of all fatal cases with acute myocardial infarction. The total hospital mortality was 19%, the highest mortality being among women over 70 years (29%). Ruptures (n = 56) were found in 17% of the hospital deaths, or 3.2% of all cases of acute myocardial infarction. Women aged less than 70 had the highest incidence of rupture, 42% of deaths being due to rupture. The mean age for patients with rupture and controls was 70.5 years. The median time after admission to death was approximately 50 hours for patients and control group A. Thirty per cent of the patients with rupture occurred within 24 hours of the initial symptoms occurring. Angina and previous acute myocardial infarction were more common among control group A. Patients with rupture and control group B were mostly relatively free of previous cardiovascular or other diseases (chronic angina pectoris ( > 2 months) and previous myocardial infarction). Sustained hypertension during admission to the coronary care unit was more common in patients than in control group A. Hypotension and shock were more common among control group A. Most (79%) of the patients who subsequently ruptured did not receive any corticosteroids at all during the hospital stay. Severe heart failure and antiarrhythmic treatment were more uncommon among patients than among control group A. Patients with rupture received analgesics approximately three times a day throughout their stay. Control group B received analgesics mostly during the first 24 hours. Thus female patients, patients with first infarcts, and patients with sustained chest pain should be investigated for the possibility of rupture. As many as one third (32%) of ruptures may be subacute, and therefore time is available for diagnosis and surgery.     

Cardiac rupture: a not infrequent complication of acute myocardial infarction. Report of five cases (author's transl)]

Five cases of cardiac rupture (CR) in acute myocardial infarction (AMI) (four men and one woman aged between 49 and 86 years, mean 64) are described. The incidence of CR was 4,7% of 106 cases of AMI and 20,8% of causes of death. In all cases, pathologic observations well agreed with electrocardiographic site of infarction. All patients had ECG pattern of transmural AMI: postero-inferior (2 cases), anterior (1 case); none of them had myocardial infarction in the past. Two patients had systolic hypertension on admission, during and immediately before death, and 3 patients were normotensive during the whole course of illness. All patients had severe, prolonged and resistant to opiate therapy chest pain, which reexacerbated immediately before death in two cases. 4 patients died within 24 hours after the onset of symptoms. Terminal ECG pattern was similar in these four cases: sudden sinus bradycardia and/or idio-ventricular rhythm, with a progressive slowing of heart rate and changes of QRS patterns of "agonic" type, preceded electrical activity cessation. In one patient, who died at the seventh day of illness, ventricular fibrillation was observed. The AA. stress the importance of the early recognition of clinical findings suggesting an impeding CR in order to relieve cardiac tamponade with pericardiocentesis and to perform, as soon as possible, surgical treatment.     

Free-wall rupture during the acute phase of myocardial infarction. Apropos of 2 cases surgically treated with success

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively. These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.     

Contrast echocardiography for detection of incomplete rupture of the left ventricle after acute myocardial infarction

Myocardial rupture is a major complication after acute myocardial infarction. With complete rupture of the free left ventricular wall cardiac tamponade occurs with fatal outcome in most cases. With partial rupture, however, hemorrhage is slower, allowing days or weeks for diagnosis. Survival of these patients strongly depends on early recognition of this complication followed by immediate surgical intervention. Echocardiography is the diagnostic tool of choice to detect myocardial rupture with consecutive hemopericardium but diagnosis remains difficult even if suspected.We describe the case of a patient with inferior infarction who presented with cardiogenic shock, echocardiographic signs of pericardial effusion and abnormal motion and myocardial irregularities of the inferior wall. With Doppler echocardiography no flow across the wall was detected. Left heart contrast echocardiography confirmed the diagnosis of suspected myocardial rupture by clear deliniation of the defect. Immediate surgical repair was successfully performed in this patient with favorable long-term outcome. Thus, echocardiography early after acute myocardial infarction is useful in detecting subsequent complications and the use of contrast echocardiography should be considered in suspected myocardial rupture.     

Survival after recurrent left ventricular free wall rupture, with an atypical occurrence after post-infarction exercise test]

Left ventricular free wall rupture is an unusual but highly lethal complication of acute myocardial infarction. We report on the extremely rare occurrence of a patient surviving two episodes of free wall rupture within a seven-month period. The first event happened in the course of an exercise testing after a seemingly uncomplicated inferior acute myocardial infarction; the second, seven months after the first, as a pseudoaneurysm in the setting of a new inferior wall infarction. Surgical repair was successful in both instances, with patient remaining asymptomatic in follow-up.     

Rupture of the free wall of the heart as cause of death in acute myocardial infarct

Twenty four cases with myocardial rupture among 259 patients with autopsy after death due to myocardial infarction, were compared with patients with acute myocardial infarction and death secondary to other causes. Myocardial rupture occured during the first 72 hours in 58% of the patients and all cases within the first five days. Two thirds of the patients were males and 46% were 70 years of age. There were 24 myocardial ruptures (9.5%). Previous history of arterial hypertension and un-remittent anginal pain were predisposing factors for rupture (p=0.05). Other previously reported bad prognostic factors such as persistent hipertension after acute infarction, severe exercise before infarction and history of Diabetes Mellitus were not statistically significant in this study. Ruptured myocardium was not influenced by a previous history of myocardial infarction, hospitalization delay in the C.C.U., administration of anticoagulants, digitalis or pressor amines. There was no significant difference among the groups compared in enzyme curves or magnitude of leucocytosis. Electromechanic dissociation, sinus bradycardia, nodal rhythm followed by idioventricular rhythm and asystole, were observed following myocardial rupture.     

Long-term course of septal rupture operated on during the acute phase of a myocardial infarct

Between 1970 and 1979, 28 patients (18 men and 10 women, aged 46 to 76 years, average 62 years) with acute myocardial infarction complicated by septal rupture survived surgery performed during the acute phase. In the same period 62 patients were admitted to the Cardiology Department and were operated early for septal rupture complicating myocardial infarction. The site of infarction was the anterior wall in 22 cases and the posterior wall in 6 cases; septal rupture occurred on average after 4.2 days (range 1 to 10 days); 15 patients including 13 with cardiogenic shock underwent intraaortic balloon pumping for an average of 3:7 (range 1 to 11 days) before surgery; the operation performed after an average interval of 11 days consisted in direct suture of the defect in 3 cases and a patch repair in the other 25 cases, associated in all cases with infarctectomy and LAD coronary bypass grafting in 1 case. The immediate postoperative course was simple; three patients with residual shunts were not reoperated. Five to 14 years later, in 1984, 4 patients had been lost to follow-up; 4 patients had died, 2 of cardiac causes (LVF after 1 year and an arrhythmia after 4 years). Of the 20 survivors, 2 were successfully reoperated (1 coronary bypass after 10 years and 1 false aneurysm after 5 years). Only one patient had recurrent myocardial infarction. The quality and longevity of long-term survival encourage early surgery. The factors affecting long-term survival are discussed: correction of associated valvular defects, resifual shunts, conservation of left ventricular function and evaluation of the coronary circulation.(ABSTRACT TRUNCATED AT 250 WORDS)     

New modalities of surgical treatment for postinfarction left ventricular free wall rupture: A case report and literature review

Left ventricular free wall rupture (LVFWR) is the third leading and most feared complication of myocardial infarction. The course of rupture varies from a catastrophic blow-out type to a subacute oozing type. The widespread availability and use of echocardiography have increased the number of cases diagnosed before death and the number of surgical cases attempted. Despite this, experience with this entity is still quite small and LVFWR remains the second most common case of death after myocardial infarction with estimated mortality of about 20%. Survival of the critically ill patients depends on the early diagnosis, hemodynamic stabilization of the patient and prompt surgical repair. The aim of an emergent operation for LVFWR is to rescue the patients at risk of death by bleeding and cardiac tamponade. We present a case of oozing type postinfarction cardiac rupture that was treated by a sutureless technique using a fibrin tissue-adhesive collagen fleece TachoSil^® (Takeda, Osaka, Japan) combined with bovine pericardial patch anchored by fibrin glue.     

Secondary splenic rupture after thrombolysis for acute myocardial infarction

Secondary splenic rupture after thrombolysis for acute myocardial infarction. HISTORY AND ADMISSION FINDINGS: A 67-year-old male patient was admitted with acute chest pain and signs of an acute anterior myocardial infarction in the ECG. The usual contraindications were excluded and after a systemic lysis with rt-PA the ECG-alterations as well as the symptoms of angina resolved completely. 2 hours later the patient developed an acute abdomen with a severe circulatory shock. INVESTIGATIONS: On ultrasound and CT a massive intraabdominal bleeding was found. TREATMENT AND COURSE: Emergency laparotomy revealed a splenic rupture. Retrospectively, 6 weeks before admission, the patient had fallen from a ladder to his left side. This is a rare case of a secondary splenic rupture during thrombolysis for acute myocardial infarction. 2 weeks later the patient developed rein-farction with angiographically shown two vessel disease. After angioplasty of the ramus interventricularis anterior (RIVA) he was stable. CONCLUSIONS: Intravenous thrombolysis in case of acute myocardial infarction is the method of choice. In the past a great number of patients were excluded from thrombolysis because of an extensive interpretation of contraindications. The aim to reach an alteration in this use may not risk health of patients by insufficient history.     

Cardiac Ruptures in Northern Norway

Abstract. In 4649 autopsies performed, in 1972–1985, 824 cases of acute myocardial infarction were found. Of these, 104 (12.6%) had cardiac rupture. Ten cases had rupture of the interventricular septum. The clinical and pathological records were reviewed, and the rupture group was compared with a control group of 100 patients who died from acute myocardial infarction without rupture. Of the patients with rupture, 85% died during the first week after the onset of myocardial infarction; three patients with rupture died suddenly without previous clinical evidence of myocardial infarction. Rupture occurred only in hearts with transmural infarcts, and predominantly in the anteroseptal wall. Patients with rupture had significantly higher blood pressure, fewer previous infarcts, higher frequency of coronary thrombi, less myocardial scar tissue and lower heart weight compared to the control group. There were no significant differences regarding age and sex distribution, physical effort at the symptom debut or death, medication, previous and present diseases other than infarcts, complications or the degree of atherosclerosis in the coronary arteries or aorta.     

Subacute rupture of the free left ventricular wall following acute myocardial infarction. Successful surgery in a case

Free left ventricular wall rupture following acute myocardial infarction usually results in cardiac tamponade and sudden death. Occasionally, the bleeding into the pericardial sac is arrested by the surrounding pericardial tissue causing formation of a pseudoaneurysm. The case herein reported presented with a refractory pericardial effusion 1 month after an anterior myocardial infarction. While echocardiography failed to reveal a pseudoaneurysm or to localize a rupture, cineventriculography disclosed the diagnosis of a minimal rupture of the left ventricular free wall. The patient was successfully treated by surgery.     

急性心肌梗死后心脏破裂的诊治进展

心脏破裂是急性心肌梗死（AMI）的机械并发症之一,往往预后不良,同时也是心肌梗死患者的第二大死亡原因。心脏破裂由于其发病突然,病情恶化迅速,目前临床治疗手段有限,病死率高,因此识别AMI后心脏破裂的高危人群,建立精准的风险预测模型,早期诊断并进行评估,及时有效的治疗尤为重要。     

Myocardial infarction and sudden death after sport: acute coronary angiographic findings

Thirteen patients, seven with acute myocardial infarction and six survivors of sudden death after sport, underwent coronary angiography within a mean of 104 min after the onset of symptoms. The admission electrocardiogram showed transmural myocardial ischemia in all patients. The ischemia-related vessel was occluded in all cases of sudden death and in three cases of acute myocardial infarction. Reperfusion was achieved in eight vessels: after intracoronary streptokinase in three, after intracoronary nitroglycerin in three, and mechanically in two. Coronary spasm was demonstrated in three vessels, and coronary thrombi, in four. The coronary lesion was described as either concentric in two or eccentric with irregular borders in eight. There was a high incidence of eccentric lesions consistent with ruptured plaques. The acute coronary angiographic findings of acute myocardial infarction and sudden death after sport are similar. Physical exercise can provoke myocardial infarction and sudden death probably by inducing plaque rupture that can evoke coronary spasm, thrombosis, or both.     

Prompt Recognition of Left Ventricular Free-Wall Rupture Aided by the Use of Contrast Echocardiography

In the modern period of reperfusion, left ventricular free-wall rupture occurs in less than 1% of myocardial infarctions. Typically, acute left ventricular free-wall rupture leads to sudden death from immediate cardiac tamponade. We present the case of a 59-year-old woman who sustained a posterior-wall myocardial infarction and subsequent cardiac arrest with pulseless electrical activity. A bedside transthoracic echocardiogram showed pericardial effusion with cardiac tamponade. Emergency pericardiocentesis yielded 500 mL of blood, and spontaneous circulation returned. Contrast-enhanced echocardiograms revealed inferolateral akinesis and a new, small myocardial slit with systolic extrusion of contrast medium, consistent with left ventricular free-wall rupture. During immediate open-heart surgery, a small hole in an area of necrotic tissue was discovered and repaired. This case highlights the usefulness of bedside contrast-enhanced echocardiography in confirming acute left ventricular free-wall rupture and enabling rapid surgical treatment.     

急性冠脉综合征患者PCI术后应用国产硫酸氢氯吡格雷的疗效

比较急性冠脉综合征（ACS）患者择期PCI术后国产氯吡格雷（泰嘉,Talcom）和进口氯吡格雷（波立维,Plavix）应用的有效性和安全性。方法：158例行择期PCI的ACS患者随机分为：国产氯吡格雷组和进口氯吡格雷组,各79例。随访12个月以上,观察两组术后不良心血管事件及药物不良反应情况。结果：进口氯吡格雷组心源性死亡1例、非致死性心肌梗死1例、靶血管再次血运重建1例、脑卒中1例。国产氯吡格雷组心源性死亡0例、非致死性心肌梗死1例、靶血管再次血运重建2例、脑卒中1例。两组心血管不良事件发生率无显著差异（5.06%比5.06%,P〉0.05）。药物不良反应：进口氯吡格雷组胃肠道反应5例、出血1例、血小板减少1例。国产氯吡格雷组胃肠道反应7例、出血1例、血小板减少2例,两组不良反应发生率无显著差异（8.86%比12.66%,P〉0.05）。结论：与进口氯吡格雷相比,国产氯吡格雷应用于PCI术后患者是安全、有效的。     

Ventricular rupture during acute myocardial infarction (author's transl)]

In a series of 523 consecutive patients with acute myocardial infarction (AMI) 112 died; among these were 18 with rupture of the free wall of the left ventricle (HR) (group RU); two other cohorts were formed: one sample of all patients with acute (transmural) myocardial infarction (group KO) and another cohort of death of AMI in 1976 (EX). 1. patients with HR are significantly older than the KO group; there is no difference in age compared to the patients who died of AMI other than HR (group EX). 2. Women with AMI have a higher chance to die of HR than men. 3. The RU group has significantly more often clinical signs of congestive heart failure than the control group. 4. Cardiogenic shock is significantly more frequent in the RU-group than in the control group. 5. All deaths (EX + RU) have worse hemodynamic data than the control group (KO). 6. Elevated blood pressure (before and after AMI) could not be identified as a risk factor for HR in our patients. 7. In the course of AMI, death in pump failure occurs significantly later than heart rupture.