Left ventricular rupture following myocardial infarction treated with streptokinase: successful resuscitation in the cardiac catheterization laboratory using pericardiocentesis and autotransfusion

Early diagnosis and rescue pericardiocentesis for acute cardiac tamponade during radiofrequency ablation for arrhythmias. Is fluoroscopy enough?

BACKGROUND

With the number of complex catheter ablation procedures increasing, procedure-related acute cardiac tamponade is encountered more frequently in the cardiac catheterization laboratory. Survival depends on prompt recognition and rescue pericardiocentesis.

OBJECTIVE

The aim of this report was to validate fluoroscopic heart silhouette characteristics associated with cardiac tamponade as a diagnostic method, and evaluate the safety and effectiveness of fluoroscopy-guided pericardiocentesis during catheter ablation.

METHODS

All cases of acute cardiac tamponade that occurred in the cardiac catheterization laboratory during radiofrequency catheter ablation from March 2004 to November 2009 were reviewed retrospectively.

RESULTS

Of 1,832 catheter ablation procedures performed during a 5-year period, 10 (0.55%) were complicated by cardiac tamponade. Fluoroscopic examination confirmed the diagnosis in all 10 patients and demonstrated effusions before hypotension in four patients. All patients were stabilized by fluoroscopy-guided pericardiocentesis with placement of an indwelling catheter and autologous transfusion. The time interval between recognition of cardiac tamponade and completion of pericardiocentesis was 6.0 ± 1.8 minutes (range 3-9 minutes). The mean aspirated blood volume was 437 mL (range 110-1,400 mL), and the mean autotransfused blood volume was 425 mL (range 100-1,384 mL). Surgical repair of the cardiac perforation was needed in one patient. No procedure-related death occurred.

CONCLUSION

A reduction in the excursion of cardiac silhouette on fluoroscopy is an early diagnostic sign of cardiac tamponade during radiofrequency ablation. Fluoroscopy-guided pericardiocentesis is a safe and effective management strategy for cardiac tamponade developed in the cardiac catheterization laboratory.

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.

Ischemic left ventricular free wall rupture: prediction, diagnosis, and treatment

Left ventricular free wall rupture is the third leading complication and the second most common cause of death after myocardial infarction. Its occurrence has been considered an unpredictable event usually leading to death. An increased appreciation for the clinical presentation of this syndrome and the nearly ubiquitous use of echocardiography have fostered a rise in the antemortem diagnosis of left ventricular free wall rupture, allowing the possibility of operative repair. Despite the increased reporting of left ventricular free wall rupture, the experience of any one surgeon or surgical group tends to be quite small. We review the current status of rupture prediction, clinical presentation, diagnosis, and treatment options. A recent case of left ventricular free wall rupture referred to the Baylor Cardiothoracic Surgery Group with the misdiagnosis of ruptured dissection of the ascending thoracic aorta is presented to illustrate our approach to this clinical situation.

Postinfarction ventricular free wall rupture: strategies for diagnosis and treatment

Ventricular free wall rupture is a recognized complication of myocardial infarction. In recent years, the widespread availability of echocardiography has enabled prompt antemortem diagnosis. Consequently, an avenue for lifesaving surgical intervention has emerged for this hitherto fatal condition. We review the pathology and discuss strategies for diagnosis, resuscitation, and definitive surgical intervention. We illustrate this review using our experience with a patient whose condition was diagnosed by transthoracic echocardiography and who successfully underwent emergency operation.