[Acute papillary muscle rupture and mitral valve insufficiency after myocardial infarction. Serious condition, but potentially curable through emergency surgery]

Acute papillary muscle rupture resulting in severe mitral regurgitation is an infrequent but extremely serious mechanical complication of myocardial infarction. The immediate and severe volume overload on the pulmonary circulation may cause pulmonary edema and circulatory shock with secondary organ failure. Diagnosis is preferably based on echocardiography, and urgent mitral valve replacement is the treatment of choice. This paper describes two such patients who were successfully treated by surgery despite cardiogenic shock. In addition, it illustrates the known fact that a papillary muscle rupture may be caused by a myocardial infarct of limited size but with an unfortunate location.

Transesophageal three-dimensional echocardiographic assessment of left ventricular pseudoaneurysm

We report an adult patient with a left ventricular pseudoaneurysm following an acute myocardial infarction in whom three-dimensional (3-D) transesophageal echocardiography (TEE) delineated clearly not only the location but also the size and shape of the rupture site. The size of the rupture site measured by 3-D TEE correlated well with the surgical measurements. Three-dimensional images also showed a localized superior distortion of the lateral aspect of the mitral annulus and left atrial wall produced by the pseudoaneurysm. The resulting severe mitral regurgitation practically disappeared after repair and decompression of the pseudoaneurysm.

Isolated acute anterolateral papillary muscle rupture presenting as a sole manifestation of acute myocardial infarction and mimicking mitral valve vegetation

We present here a case of an acute myocardial infarction presenting solely as rupture of the head of anterolateral papillary muscle of the mitral valve with an echocardiographic appearance of a mitral valve vegetation. A 61-year-old male patient presented to the hospital with cardiogenic shock. Transesophageal echocardiography revealed normal left ventricular global and regional systolic function with the echocardiographic appearance of a large vegetation attached to the anterior mitral valve leaflet and severe mitral regurgitation. Intraoperatively, an infracted and ruptured head of the anterolateral papillary muscle was found with no evidence of vegetations. Papillary muscle rupture is a rare complication of acute myocardial infarction, is usually associated with inferior myocardial infarction and rarely seen as the only clinical and echocardiographic finding. Transesophageal echocardiography is more sensitive than transthoracic echocardiography but misdiagnosis can still occur.

Review of ventricular rupture: key concepts and diagnostic tools for success

Although a rare complication of acute myocardial infarction (AMI), ventricular rupture is a serious event associated with significant mortality and morbidity. Patients normally present with hemodynamic instability, often in cardiogenic shock. Despite improvements in surgical techniques and diagnostic tools, post-myocardial infarction ventricular rupture remains a difficult therapeutic challenge. There are three categories of ventricular rupture: free wall rupture (FWR), ventricular septal rupture (VSR), and papillary muscle rupture (PWR). The incidence of FWR occurs following up to 10% of myocardial infarctions. VSR and PWR have a lower incidence of 1-2% and 0.5-5%, respectively. Patients often present with single-vessel coronary artery disease and usually do not have a positive history for a previous myocardial infarction. The incidence of post infarction angina in these patients is significantly greater than in patients without ventricular rupture. Delay in treatment and continued physical activity post infarction increases the risk of ventricular rupture. Diagnostic tools such as two-dimensional echocardiography and cardiac catheterization confirm the diagnosis of ventricular rupture in only 45-88% of cases. Knowledge of the disease progression is necessary to insure accurate and timely diagnosis. Due to the rapid deterioration of these patients, there is a 50-80% mortality rate within the first week if untreated. With surgical correction, patients can extend their 5-year survival rates to 65%. A good example of the complex course of ventricular rupture is the case of a 71-year-old patient at our institution. The patient presented in cardiogenic shock following an AMI. Preoperative diagnosis was unsuccessful in determining the extent of the ventricular rupture. The correct diagnosis was determined in the operating room, and both a mitral valve replacement and closure of a ventricular septal defect were completed. The patient was successfully treated with this difficult pathology.

[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.

Ventricular septal rupture caused by myocardial bridging

A 70-year-old woman was referred to us with postinfarction angina. During cardiac catheterization the only coronary abnormality found was myocardial bridging in the mid and distal parts of the left anterior descending coronary artery, despite a large ventricular septal rupture. The pulmonary-to-systemic flow ratio was 2.5:1. Her operation was successful.

Postinfarction left ventricular rupture misdiagnosed ruptured intramural hematoma of aorta

Left ventricular rupture is a fatal complication of acute myocardial infarction, however accurate preoperative diagnosis is still difficult. We experienced a postinfarction left ventricular rupture patient whose symptoms and radiologic findings mimicked those of acute intramural hematoma of the aorta. Upon emergency operation, he was proven to have a postinfarction LV rupture and underwent successful surgery. We herein report the case with a brief review of the literature.

Ventricular free wall rupture in acute myocardial infarction

Despite a progressive reduction in acute myocardial infarction mortality over the years, death related to ventricular free wall rupture has not changed. This is mostly related to the catastrophic presentation and death within minutes in the majority of these patients. Once rupture is suspected, bedside echocardiography should be performed immediately, followed by pericardiocentesis and repair of the rupture site as quickly as possible. Measures to prevent cardiac rupture include the administration of beta-blockers and angiotensin-converting enzyme inhibitors unless contraindications exist, and the avoidance of steroidal and nonsteroidal anti-inflammatory agents such as ibuprofen and indomethacin.

[Rupture of the interventricular septum in lower myocardial infarction with asymptomatic onset]

We report the case of a 69-year-old patient with no history of cardiac problems referred to us for dyspnea. A major systolic murmur was found and the echocardiogram revealed an interventricular septal defect. The ECG showed no signs of acute myocardial infarction that was established on the basis of myocardial enzymes. The patient was hemodynamically stabilized by intra-aortic balloon pumping. A later coronarography revealed one-vessel coronary artery disease. Then the patient underwent successful surgical repair of the septal defect.

Brain natriuretic peptide and cardiac rupture after acute myocardial infarction

Cardiac rupture is a fatal complication in the acute stage of myocardial infarction (MI). However, no measures have yet been established to predict it. Herein we describe three MI patients with cardiac rupture in whom plasma brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) concentrations had been serially monitored from the onset of MI to cardiac rupture. In these cases, plasma BNP levels increased without symptomatic and hemodynamic changes and reached their highest level immediately before cardiac rupture, while plasma ANP levels remained unchanged. These cases suggest that the increased plasma BNP concentrations without symptomatic and hemodynamic changes may be a useful marker for predicting cardiac rupture after acute MI.

Subacute left ventricular free wall rupture

In a 59-year-old man, Left ventricular free wall rupture following acute myocardial infarction was diagnosed by transthoracic echocardiography, left ventriculography and a combination of saline injection into the left ventricle and concomitant transthoracic echocardiography. The Operation was successfully performed with an extracorporeal bypass on the beating heart. Some technical aspects of the treatment are discussed.

Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?

OBJECTIVES

We sought to compare the characteristics and outcomes of patients with acute myocardial infarction (MI) and cardiogenic shock (CS) caused by rupture of the ventricular free wall or tamponade versus shock from other causes.

BACKGROUND

Free-wall rupture is a recognized cause of mortality in patients with acute MI. Some of these patients present subacutely, which provides an opportunity for intervention. Recognition of factors that distinguish them from the overall shock cohort would be beneficial.

METHODS

The international SHOCK Trial Registry enrolled patients concurrently with the randomized SHOCK Trial. Thirty-six centers consecutively enrolled all patients with suspected CS after MI, regardless of trial eligibility.

RESULTS

Of the 1,048 patients studied, 28 (2.7%) had free-wall rupture or tamponade. These patients had less pulmonary edema, less diabetes, less prior MI, and less prior congestive heart failure (all p < 0.05). They more often had new Q waves in two or more leads (51.9% vs. 31.5%, p < 0.04), but MI location and time to shock onset after MI did not differ. Of patients with rupture or tamponade, 75% had pericardial effusions. No hemodynamic characteristics identified patients with rupture/tamponade. Most patients with rupture/tamponade had surgery and/or pericardiocentesis (27/28); their in-hospital survival rate was identical to that of the group overall (39.3%). Women and older patients with rupture/tamponade tended to survive intervention less often.

CONCLUSIONS

Free-wall rupture and tamponade may present as CS after MI, and survival after intervention is similar to that of the overall shock cohort. All patients with CS after MI should have echocardiography in order to detect subacute rupture or tamponade and initiate appropriate interventions.

Primary coronary angioplasty in acute myocardial infarction: is it possible to prevent postinfarction cardiac rupture?

BACKGROUND

Cardiac rupture is a leading cause of death among patients hospitalized for acute myocardial infarction (AMI). The aim of our retrospective study was to evaluate the impact of primary coronary angioplasty (PTCA) on this not common but usually fatal complication.

METHODS

Since January 1998 PTCA has been the routine treatment for AMI patients in our Institution monitored during the first 12 hours from symptom onset. The AMI patients hospitalized between January 1998 and December 1999 (Group A) were retrospectively compared to those observed between January 1996 and December 1997 (Group B, historical control group), mainly treated with systemic thrombolysis. Patients hospitalized after 12 hours of symptom onset were excluded from the study. Data were analyzed on an intention-to-treat design.

RESULTS

Group A consisted of 204 patients (148 males, 56 females, mean age 67 +/- 11 years), 165 (81%) of whom underwent coronary angiography. Group B consisted of 185 patients (123 males, 62 females, mean age 71 +/- 12 years), 78 (42%) of whom were treated with thrombolysis and 33 (18%) with PTCA. The groups did not differ as regards the time delay before hospital entry, Killip class at admission and site of AMI. Fourteen patients (6.8 %) of Group A and 20 (10.8%) of Group B died in the Cardiology Division. No deaths due to cardiac rupture were observed among the 165 Group A patients, nor among the 33 Group B patients treated with PTCA. Cardiac rupture was the cause of death for 1 out of 14 (7%) patients in Group A, and for 8 out of 20 (40%) patients in Group B (p < 0.02 Group A vs Group B). Nine Group A patients and 11 Group B patients died because of cardiogenic shock.

CONCLUSION

A lower cardiac rupture incidence was observed among Group A patients in comparison to those of Group B. Thus our data, although not randomized, suggest the ability of primary PTCA in preventing post-AMI cardiac rupture.

Cardiac rupture and admission electrocardiography in acute anterior myocardial infarction: implication of ST elevation in aVL

This study determines the usefulness of electrocardiography in the emergency room for assessing the risk of cardiac rupture after acute anterior myocardial infarction (MI). The presence of ST segment elevation on the admission 12-lead electrocardiography was evaluated in 325 consecutive anterior MI patients. A forward-stepwise logistic regression analysis for cardiac rupture was performed with the covariates of age, gender, hypertension, history of MI, reperfusion therapy by coronary angioplasty, and ST segment elevations in leads I, aVL, V1-V6. Cardiac rupture occurred in 16 patients, including 7 with left ventricular free wall rupture (FWR) and 9 with ventricular septal perforation (VSP). For FWR, ST elevation in lead aVL was the only independent predictor (odds ratio = 12.1, P = .0215). For VSP, female gender (odds ratio = 5.32, P = .0201) was the independent predictor. In conclusion, in patients with acute anterior MI, ST segment elevation in lead aVL on the admission electrocardiography is a significant risk factor for left ventricular FWR.

Posterior-septal pseudo-pseudoaneurysm with limited left-to-right shunt: an unexpected easy repair

Cardiac rupture represents a fatal complication of acute myocardial infarction within the first two weeks. In exceptional cases, the postinfarction rupture of the myocardium is not transmural but remains circumscribed within the wall itself as a cavity joined to the left ventricle through a narrow neck. This finding is usually defined as pseudo-pseudoaneurysm. We report a rare case of postinfarction posterior pseudo-pseudoaneurysm of the left ventricle, perforated into the right ventricle. This unusual anatomy resulted, over a period of several years, by progressive intramural dissection of the surrounding necrotic myocardium with late formation of a large, partially fibrotic chamber, communicating either with left and right ventricles. Despite correct preoperative diagnosis was not achieved by 2D echocardiography, pulsed Doppler and contrast ventriculography, a successful surgical treatment was possible with a really good outcome.

[Fatal ventricular rupture after stent implantation in acute myocardial infarct with subsequent stent thrombosis: discussion of reperfusion injury as the cause]

Ventricular rupture due to myocardial infarction is a well-known but rare complication. Since the introduction of thrombolytics or acute PTCA in the management of acute myocardial infarction, the frequency of this complication has further decreased. A case of lethal ventricular rupture in the course of acute stenting for myocardial infarction, acute stent thrombosis 7 hours after successful intervention, and successful reintervention with intracoronary administration of abciximab is reported. Myocardial rupture as a severe form of reperfusion injury is discussed.

Subacute left ventricular free-wall rupture in early course of acute myocardial infarction. Clinical report of two cases and review of the literature

Left ventricular free wall rupture (LVFWR) may complicate an acute myocardial infarction (AMI); its frequency ranges from 1 to 6 percent. In the era of coronary care units, LVFWR is the second cause of in-hospital death, after pump failure. The subacute presentation accounts for 2-3 percent of total hospital admissions for AMI. Heart rupture may not be suddenly fatal and sometimes there is enough time for surgical repair. Electromechanical dissociation is neither the only nor the main clinical presentation. More subtle symptoms occurring hours or days before the final event include unexplained hypotension and transient bradycardia and some ECG features such as persistent ST-segment elevation with T-waves failing to invert in the same leads. On echocardiographic subcostal view, pericardial effusion of more than 5-10 mm, with echo-dense masses overlying the heart independently of cardiac tamponade, is highly suggestive of heart rupture. If pericardiocentesis yields hemorrhagic fluid, surgical intervention is mandatory, providing both diagnostic confirmation and definitive treatment. Medical management strategies (prolonged bed rest, beta-blockade therapy) are still experimental but could become suitable for particular subsets of patients (elderly patients and patients at a high surgical risk). We report two cases of subacute LVFWR and review the currently available literature.

[The recurrence of a postinfarct interventricular defect. An alternative approach]

Despite improvement of surgical techniques and perioperative management, the postinfarction ventricular septal defect still remains a surgical challenge associated with a significant early and late mortality. Furthermore, the recurrence of the defect after primary correction occurs in about 10-25% of patients and the operative risk increases because of difficult dissection that is often complicated by previous patent grafts. Repair of recurrent posterior postinfarction ventricular septal defect has generally been performed by ventriculotomy in the infarcted zone. This approach carries a significant mortality and morbidity from hemorrhage or further compromise of ventricular function. We propose an alternative approach to a recurrent defect that, when the rupture is posterior, makes it possible to achieve its complete visualization, avoiding any further ventriculotomy in an already impaired ventricle. This transatrial approach seems to be a safe technique. Moreover, the simplicity of this operation and the patient's rapid recovery contrasts remarkably with the transventricular approach used in previous patients. Nevertheless, care must be taken to avoid damage to the tricuspid valve.