Ventricular free wall rupture following acute myocardial infarction

SUMMARY: Ventricular free wall rupture remains a dreaded complication of acute myocardial infarction. A dramatic fatal presentation is not universal and if recognized early, especially in its sub-acute form, a therapeutic intervention may be lifesaving. Changing trends in its natural history and the previously described pathological subtypes have emerged since the advent of thrombolysis. Although frequently unpredictable, certain clinical, echocardiographic and electrocardiographic signs should suggest the diagnosis. Moreover, knowledge of predisposing risk factors and a high index of suspicion are helpful in early recognition of this complication. In recent years, several different therapeutic approaches have been described including percutaneous seals and surgical mechanical closure of ventricular free wall rupture. In this review, we sought to highlight established and debatable aspects of this pathology to hopefully enhance prompt diagnosis and treatment by all clinicians caring for patients suffering acute myocardial infarction.     

Left ventricular free wall rupture in acute myocardial infarction: a case report and literature review

We describe a case of subacute left ventricular free wall rupture during acute myocardial infarction in a 68-year-old man. The diagnosis was confirmed by echocardiography. The patient was supported by an intra-aortic balloon pump until the ruptured wall could be successfully repaired by suturing and gluing a pericardial patch over the defect and bypassing the left anterior descending coronary artery with a vein graft. This case demonstrates that left ventricular free wall rupture is not always fatal and that early diagnosis and institution of intra-aortic balloon pump support in such patients can allow successful bridging to definitive emergency surgical therapy.     

Left ventricular free wall rupture after acute myocardial infarction(The 21th case)

患女性，69岁，退休，以胸闷16h入院。患活动后发病，逐渐出现呼吸困难。否认既往冠心病病史，合并高血压。入院时查体体温36．5℃，心率110次／min，呼吸27次／min，血压90／60mmHg。精神差，心律齐，心音低钝，各瓣膜区未闻及杂音。心尖部可闻及舒张期奔马律，双肺可闻及中到大量湿哕音。急诊心电图：窦性心动过速，前壁及高侧壁导联ST段抬高0．1～0．3mV，Q波形成。心肌酶升高。诊断急性广泛前壁心肌梗死。[第一段]     

Cardiac rupture caused by myocardial infarction in the diagonal branch area: evaluation by cardiac multislice computed tomography: a case report

A 75-year-old woman was admitted to the emergency room because of hypotension and loss of consciousness induced by cardiac tamponade. Electrocardiography revealed ST elevation and laboratory data showed elevation of serum creatine kinase and troponin I. The patient was referred to the cardiology department 5 days later. Cardiac catheterization revealed ventricular aneurysm in the anterior wall, significant stenosis (75%) in the left anterior descending coronary artery and subtotal stenosis (99%) in the diagonal branch. Cardiac multislice computed tomography suggested that the ventricular pseudoaneurysm was probably due to cardiac rupture caused by myocardial infarction in the diagonal area. Subsequently, aneurysmectomy and coronary artery bypass graft surgery were performed. Cardiac multislice computed tomography is useful for evaluating coronary artery and cardiac rupture.     

Ventricular free wall rupture following acute myocardial infarction: a two-dimensional echocardiographic assessment

To assess the usefulness of two-dimensional echocardiography (2DE) in diagnosing ventricular free wall rupture following acute myocardial infarction, we studied the 2DE findings and the clinical pictures of seven consecutive patients with ventricular free wall rupture confirmed at the time of surgery or autopsy. Three patients had acute rupture; four, subacute rupture. All patients apparently had circulatory collapse despite continuing electrical activity at the onset of cardiac rupture. Four patients with subacute rupture recovered. In all patients, mild pericardial effusion was imaged by 2DE; however, this was not characteristic for cardiac rupture. In the patients with acute rupture, active left ventricular contractions were not observed after each QRS complex of the electrocardiogram. However, weak mitral valve motion was recorded at the time of cardiopulmonary resuscitation. The interesting and constant finding in acute rupture was the right ventricular collapse observed throughout the cardiac cycle. Diastolic right ventricular collapse was consistently observed in patients with subacute rupture, immediately after recovery from cardiogenic shock. Subacute cardiac rupture is a potentially curable lesion, and the clinical features and quick 2DE confirmation of cardiac tamponade allowed immediate surgery which saved two of the four patients.     

A case of ventricular free wall rupture in acute myocardial infarction treated conservatively with success

A sixty year old man developed clinical signs of pericardial tamponade on fifth day of acute myocardial infarction. An echocardiogram showed a pericardial effusion and rupture of left ventricular free wall. After pericardial puncture and four days pericardial drainage, the fissure of rupture was closed by formation of thrombus and pseudoaneurysm. After six weeks patient was discharged in good condition.     

Myocardial free wall rupture and thrombolytic therapy in acute myocardial infarction

We investigated the relation between myocardial free wall rupture and thrombolytic therapy in 200 patients with acute myocardial infarction (AMI). Ten of 200 patients (5.0%) were complicated with cardiac rupture, and all of them died within 70 hours after the onset (29% of the deceased after AMI). The pathophysiologic study of 5 patients undergoing autopsy after cardiac rupture was performed. In 4 patients receiving thrombolysis, autopsy revealed massive hemorrhagic infarction and teared lesion near the center of infarcted area. We assessed that the location of teared lesion might be influenced by broad hemorrhagic infarcted area following thrombolytic therapy. The incidence of cardiac rupture was slightly higher in the group receiving thrombolysis in the early stage of AMI than conventional treatment group. Among the patients receiving thrombolytic therapy, some cases revealed markedly increased fibrinolytic activity. This suggested that such elevated fibrinolytic activity might induce massive hemorrhagic infarction and might be an important factor contributing to the cardiac rupture. Thrombolytic therapy has been frequently reported to improve cardiac function and prognosis, but our study suggests that thrombolytic therapy must be evaluated moreover as one of the risk factors of cardiac rupture.     

Early diagnosis of subacute free wall rupture complicating acute myocardial infarction

Of 2608 consecutive patients with acute myocardial infarction,24 developed subacute free wall rupture (=0.92%; 95% C.I.=0.6–1.4).Clinical manifestations varied widely (shock on admission: 25%of cases; severe arrhythmias followed by shock: 17%; shock duringhospital stay: 42%; symptoms suggestive of infarct extensionwithout shock: 17%). The electrocardiograms were confusing ratherthan revealing: 56% of patients showed new ST segment elevationsof 0.2 to 1 mV in the infarct-related leads, while autopsy orcreatinine phosphokinase evidence of infarct extension was missing.In the first 21 cases, therefore, no definitive diagnosis wasmade before autopsy. Using 197 infarct patients in cardiogenic shock or with infarctextension during the acute stage, i.e. a patient group withcomparable clinical manifestations, as control group, a logisticregression model was generated in which the variables age, lateralwall involvement and history of hypertension were used for estimatingthe probability of subacute rupture. In fact, probability mayrise to more than 40% in major subgroups. As death occurred after a median interval of 8 h (45 min–6.5weeks) following the onset of rupture symptoms, echo-cardiographymust be performed urgently in all cases presenting symptomsof shock or infarct extension. Pretest probability which canbe roughly estimated from our model as well as sensitivity andspecifity of individual echocardiographic or clinical parametersare indispensable for correct therapeutic decisions. The routineapplication of this algorithm in our department contributedto a timely diagnosis in the last three consecutive cases ofwhom one patient survived.     

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.     

Ventricular septal rupture complicating surgically treated left ventricular free wall rupture in a patient with acute myocardial infarction. A case report

There is a group of rare but serious complications of acute myocardial infarction (AMI), including free wall rupture (FWR) and, less frequent, ventricular septal rupture (VSR). Urgent surgery combined with simultaneous CABG is usually a treatment of choice. We present a case of a 65-year-old male with AMI, who developed cardiogenic shock due to cardiac tamponade as a result of FWR. The patient was successfully resuscitated and operated. During postoperative treatment parasternal systolic murmur was audible and VSR diagnosis was confirmed. Three months after AMI the AMPLAZER Muscular VSD Occluder was successfully implanted. The follow-up period was uneventful.     

急性ST段抬高心肌梗死患者发生心室游离壁破裂的危险因素分析

目的：分析急性ST段抬高心肌梗死（STEMI）患者发生心室游离壁破裂（FWR）的危险因素。方法回顾性分析武汉亚洲心脏病医院心内科2005年1月至2010年7月间确诊为STEMI患者（1247例）的临床资料,其中发生FWR的患者29例。将患者分为静脉溶栓组、直接经皮冠状动脉介入治疗（PPCI）组和未再灌注治疗组。结果 FWR总体发生率为2.3%,其中静脉溶栓治疗患者128例（10.2%）,发生FWR 6例（4.7%）;接受PPCI患者623例（50.0%）,发生FWR 2例（0.3%）;未再灌注治疗患者496例（39.8%）,发生FWR 21例（4.2%）。FWR组与非FWR组间临床特点比较,高龄（70.2±9.09岁比63.2±11.23岁,P=0.042）、合并高血压病史（62.1%比33.0%,P=0.013）、糖尿病病史（55.2%比23.5%,P=0.022）、合并心力衰竭（Killip分级≥Ⅱ级）（58.6%比21.9%,P=0.012）,既往无陈旧性心肌梗死患者（10.3%比18.4%,P=0.018）等项的差异均有统计学意义;经多因素Logistic逐步回归分析显示年龄（≥70岁）、心功能（Killip≥Ⅱ）、静脉溶栓治疗、高敏C反应蛋白（hsCRP）＞100 mg/L与心肌梗死后发生FWR相关。结论高龄、心力衰竭、静脉溶栓治疗以及hsCRP＞100 mg/L是预测FWR发生的独立危险因素。     

Cardiac free wall rupture in acute myocardial infarction: ameliorative effect of coronary reperfusion.

To investigate the pathophysiology of cardiac free wall rupture (cardiac rupture) following acute myocardial infarction (AMI), and to clarify whether reperfusion therapy prevents cardiac rupture, 1,329 cases of AMI (conventional therapy group: 807 cases and reperfusion therapy group: 533 cases) were studied retrospectively. The overall incidence of cardiac rupture was 2.3% (2.7% in the conventional therapy group vs. 1.7% in the reperfusion therapy group). Patients with cardiac rupture were divided into two subgroups according to the time interval from the onset of AMI to cardiac rupture (early rupture less than or equal to 72 h and late rupture greater than or equal to 4 days). The indices of initial evolution of AMI was a significant risk of early cardiac rupture. The reperfusion therapy group showed significantly lower incidence of late rupture (0.4 vs. 1.5% in conventional therapy group; p less than 0.05). The incidence of cardiac rupture in the unsuccessful reperfusion therapy group was higher than that of the successful group (5.9% of 118 cases vs. 0.5% of 404 cases; p less than 0.05). It is concluded that the etiology of cardiac rupture following AMI cannot be explained by any single factor. Early rupture depends on the initial evolution of AMI, and early reperfusion and collateral flow prevent the late onset cardiac rupture.     

Acute myocardial infarction complicated by LV free wall rupture: the benefits of echocardiography

The recent increase in the number of cases of left ventricularfree wall rupture being diagnosed before death and in the numberof surgical repairs attempted is largely due to echocardiography.We report a case that highlights the value of echocardiographyin the diagnosis and treatment of left ventricular free wallrupture following acute myocardial infarction.     

Left ventricular free wall rupture after reperfusion therapy for acute myocardial infarction

We evaluated the clinical significance of angiographic indexes and pericardial involvement in predicting increased risk of free wall rupture after reperfusion therapy and found that Thrombolysis In Myocardial Infarction (TIMI) <3 flow grade after reperfusion therapy was a significant variable related to the free wall rupture. Moreover, pericardial rub was found to be a significant variable related to TIMI <3 grade flow after reperfusion, which indicates that detection of pericardial rub is one of the clinical signs that predicts inadequate anterograde flow of the infarct-related artery after reperfusion and hence, higher risk for free wall rupture.