Subacute ventricular free wall rupture complicating myocardial infarction

Cardiac rupture during acute myocardial infarction : Autopsy study (2004-2020)

INTRODUCTION

Cardiac rupture is a rare but critical complication of myocardial infarction with an incidence of 1 to 3% of cases. We aimed in this autopsy study to analyze the anatomical, epidemiological, cardiac, and coronary profiles of cardiac rupture in the Monastir region.

METHODS

We conducted a descriptive study with retrospective data collection of all cases of myocardial infarction complicated by a cardiac rupture over seventeen years (2004-2020).

RESULTS

Thirty-one cases were included in this study. The mean age of the cases was 67 years with a male predominance. Sixteen cases (57%) had cardiovascular risk factors. The most common symptomatology reported before death was acute chest pain in 57% of cases. Fourteen cases (45%) corresponded to the definition of sudden cardiac death. At autopsy, the heart had a mean weight of 452.78 grams. A large hemopericardium was associated in 90% of cases. Myocardial rupture involved the posterior wall of the left ventricle in 50% of cases. The myocardial rupture occurred at a site of acute myocardial infarction in 86% of cases and on a myocardial scar in 14% of cases. The coronary study showed double or triple vessel atherosclerotic coronary artery disease in 57% of cases with fresh thrombi at the infarct-related coronary in 11% of cases.

CONCLUSIONS

Our analysis found that cardiac rupture mostly involved elderly subjects with underlying cardiovascular risk factors. Our findings sustain that age is a determining prognostic factor after acute coronary syndrome with the need for further education and awareness-raising efforts to speed up access to care for these patients.

Perioperative Management of a Patient With Left Ventricular Free Wall Rupture After Myocardial Infarction: A Rare Case Scenario

Myocardial infarction (MI) is typically followed by numerous lethal complications. One such complication is left ventricular free wall rupture (LVFWR). We present the case of a middle-aged hypertensive patient who had a history of unstable angina for seven days. He presented to the emergency room with chest pain, dyspnea, and unstable vital parameters. Clinical signs, electrocardiography, and echocardiography raised the suspicion of left ventricular free wall rupture with ST-segment elevation inferior wall and lateral wall MI. As a result, the patient received aggressive resuscitative measures. Later, he underwent surgical repair for cardiac rupture via cardiopulmonary bypass. Finally, the patient was discharged from the hospital on the 10^th postoperative day. The window period from the onset of cardiac wall rupture to patient admission to the operating room is crucial. This case report highlights that a high index of suspicion for left ventricle free wall rupture should be considered for a patient presenting with MI and cardiogenic shock. Timely diagnosis and quick surgical intervention can deter complications and save the patient.

Managing Thrombosis and Hemorrhage in a Man with Myocardial Infarction and Traumatic Hemopericardium with Cardiac Tamponade

A 79-year-old man had an out-of-hospital acute ST-segment-elevation myocardial infarction with cardiac arrest. Cardiopulmonary resuscitation performed by a bystander resulted in traumatic hemopericardium. We discuss the patient's case, highlight the challenges of managing simultaneously life-threatening thrombosis and hemorrhage, and present our conclusions regarding the patient's eventual death.

Left ventricular free wall rupture in myocardial infarction: A retrospective analysis from a single tertiary center

Objective

Left ventricular free wall rupture (LVFWR) is a rare but severe complication of acute myocardial infarction (AMI). During the era of pre-thrombolysis, autopsies revealed an incidence of approximately 8%.

Method

The objective of this retrospective study was to analyze the current incidence of LVFWR and to identify predictors by comparing the AMI-cohort with LVFWR to those without. The control group involved a random selection of one in every ten patients who presented with acute myocardial infarction between 2005 and 2014.

Result

A total of 5143 patients with AMI were treated at the Central Hospital, Bad Berka (71% men, median age 68 years). Out of these, seven patients with LVFWR were identified with an overall incidence of 0.14%. Clinically, LVFWR patients presented late to admission since symptom onset (median 24 h vs. 6.1 h; p < 0.0001), were more likely in cardiogenic shock (28.6% vs. 3.2%; p = 0.02) and were usually accompanied by emergency physicians (71.4% vs. 20.7%; p = 0.006). Higher troponin T (median 8.6 vs. 0.5 ng/ml; p < 0.0002), higher CRP (median 50 vs. 0.5 mg/l; p = 0.05) as well as a lower hematocrit-values (0.33 vs. 0.42; p = 0.04) were observed. All LVFWR patients were operated (100% vs. 1.6%; p < 0.001). The patients had lower rates of beta-blocker treatment (57.1% vs. 95.8%; p = 0.003). The 30-day mortality was significantly higher (42.9% vs. 6.8%; p = 0.01).

Conclusion

Compared to the thrombolytic era, the current incidence of LVFWR with AMI, who reach the hospital alive, is significantly lower. However, 30-day mortality continues to be high.

Successful Percutaneous Closure of Traumatic Right Ventricular Free Wall Rupture Using Amplatzer Vascular Plug Devices

Ventricular free wall rupture (VFWR) is a rare entity and is mostly related to post myocardial infarction (MI) complications usually involving left ventricle. In traumatic chest injuries, the right ventricle (RV) is more commonly involved due to its anatomic and structural vulnerability, as in our case. Survival, although rare, has almost always been secondary to urgent surgical repair, which is the current standard of care for such cases. However, extremely tenuous hemodynamic parameters preclude urgent surgical interventions in most of these cases. Surgical repair was considered to have prohibitive risk in our case also due to multiple comorbidities. Our case offers a unique perspective into the feasibility and safety of percutaneous closure of VFWR with devices such as Amplatzer Vascular Plug (AVP) II under transesophageal echocardiography (TEE) and angiographic guidance in patients who survive VFWR. The lack of randomized evidence to standardize the duration and regimen of antiplatelet therapy following placement of these devices is to be noted.

Successful emergent repair of a subacute left ventricular free wall rupture after acute inferoposterolateral myocardial infarction

Background

Myocardial rupture is an important and catastrophic complication of acute myocardial infarction. A dramatic form of this complication is a left ventricular free wall rupture (LVFWR).

Case presentation

A 70-year-old man with acute inferoposterolateral myocardial infarction and single-vessel coronary artery disease underwent emergency percutaneous coronary intervention (PCI). The circumflex coronary artery was successfully stented with a drug-eluting stent. Fifty days after PCI the patient experienced progressive fatigue and chest pain with haemodynamic instability. Transthoracic echocardiography showed a covered LVFWR of the lateral wall. The patient underwent successful emergent surgical repair of the LVFWR.

Conclusions

In the current era of swift PCI, mechanical complications of acute myocardial infarction, such as LVFWR, are rare. The consequences, however, are haemodynamic deterioration and imminent death. This rare diagnosis should always be considered when new cardiovascular symptoms or haemodynamic instability develop after myocardial infarction, even beyond one month after the initial event. Timely diagnosis and emergency surgery are required for successful treatment of this devastating complication.

Ventricular free wall Rupture after Myocardial Infarction

Patients with their first myocardial infarction (MI), who present to the emergency department many hours after the onset of chest pain, who appear to be improving but suddenly develop new chest pain and unexpected hypotension (with or without signs of cardiac tamponade), should be suspected of having ventricular free wall rupture (VFWR). The mainstay of treatment is surgery. These patients may be managed with the administration of fluids, cautious use of inotropes and echocardiographic scanning, which should be performed on an emergent basis, while being prepared to be moved to the emergency surgical suite. However, at no cost should surgery be delayed. This paper reviews the current literature of VFWR after MI, a condition which remains difficult to diagnose, in many aspects, to this day. The review examines the historical background, incidence, postulated risk factors, clinical presentation, investigations and management.

The Role of Echocardiography in Acute Myocardial Infarction

The indications for echocardiography in the setting of acute myocardial infarction are to identify wall motion abnormalities, to evaluate left and right ventricular function, and to exclude complications such as pericarditis, mitral regurgitation, and ventricular rupture. Doppler echocardiography can provide important hemodynamic information. In the near future, contrast echocardiography can be expected to delineate myocardial perfusion and three-dimensional echocardiography to better define infarct size.

Surgical Approach to Myocardial Rupture after Acute Myocardial Infarction

Rupture of the ventricular wall is a highly lethal complication of acute myocardial infarction that is diagnosed more frequently with the increased use of two-dimensional echocardiography. External patching techniques were used to treat 4 patients with ventricular rupture, thus avoiding resection of necrotic myocardium. Three of the patients survived. One patient developed a large left ventricular pseudoaneurysm requiring reoperation. The other 2 patients had intact repairs on follow-up echocardiogram obtained after 5 weeks and 3 years, respectively. With prompt recognition and treatment, patient survival and excellent short-term results can be achieved.

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.

Echocardiography and Cardiac Rupture: Is Contrast Extravasation an Indication for Surgery?

Contrast echocardiography demonstrating microbubbles in the pericardial space has often been cited as evidence of ventricular rupture requiring emergent surgical intervention. We report a case where no myocardial perforation was found during post-myocardial infarction surgery despite prior echocardiographic evidence of contrast extravasation into the pericardial effusion. Clinical decision making requires balancing imaging evidence with clinical circumstances to determine the optimal timing for surgical intervention.

Cardiac rupture

BACKGROUND

Cardiac rupture is an unusual cause of chest pain and sudden cardiovascular collapse. This diagnosis may be easily forgotten while managing a patient in extremis in the initial minutes of evaluation and resuscitation in the emergency department (ED).

OBJECTIVES

To report the benefit of immediate bedside cardiac ultrasonography in the diagnosis of cardiac rupture and its influence on emergent intervention in the ED.

CASE REPORT

The initial electrocardiogram, performed within 5 min of arrival, of a 65-year old man who presented with 20 min duration of chest pain, showed a biphasic T wave in V1 and inverted T wave in V2, without ST-segment elevation myocardial infarction. Fifteen minutes later, he lost consciousness and was pulseless without a shockable rhythm on the monitor. Chest compressions were started and the patient was intubated. Echocardiography was performed at the bedside by the emergency physician. Cardiac contractility was grossly decreased in both ventricles and a large amount of pericardial fluid was seen. Two attempts at ultrasound-guided pericardiocentesis yielded only a few milliliters of blood. Interruptions in chest compressions were minimized during pericardiocentesis. Before transport of the patient to the operating room for definitive repair, asystole occurred. On the subsequent echocardiogram, heart contractions were absent and a hematoma was seen in the pericardial space. Resuscitation efforts were stopped. An autopsy was not performed per family request.

CONCLUSIONS

Typical ultrasonographic findings of cardiac rupture were present in this patient, who presented in extremis with chest pain. Early bedside echocardiography can be helpful in directing the initial care of critically ill patients.

Cardiogenic shock in ACS. Part 1: prediction, presentation and medical therapy

Ischemic cardiogenic shock is a complex, self-perpetuating pathological process that frequently causes death irrespective of medical therapy. Early definition of coronary anatomy is a pivotal step towards survival. Those destined to develop shock are likely to have three-vessel or left main stem disease with previously impaired left ventricular function. Early reperfusion of the occluded artery can limit infarct size, but ischemia-reperfusion injury or the 'no-reflow' phenomenon can preclude improvement in myocardial contractility. Emergence of shock depends upon the volume of ischemic myocardium, stroke volume, and peripheral vascular resistance. If cytokine release triggers the systemic inflammatory response, systemic vascular resistance falls and inadequate coronary perfusion pressure heralds the downward spiral. Survival depends on early recognition of shock, followed by aggressive targeted treatment of left, right, or biventricular failure. The goal is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial pressure, which is achieved with inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption, and extended ischemia. The value of intra-aortic balloon counter-pulsation is now questioned in patients with advanced shock. When mean arterial pressure is <55 mmHg with serum lactate >11 mmol/l, death is likely and mechanical circulatory support becomes the only chance for survival.

Medium-term echocardiographic follow-up of systolic and diastolic left ventricular abnormalities after surgical treatment of subacute rupture

Subacute rupture of the left ventricular free wall is a complication that occurs during the acute phase of a myocardial infarction. The subacute presentation makes surgical management possible. However, it is not known whether either pericardial manipulation or the use of pericardial patches influences left ventricular function over the medium term. Our aim was to monitor changes in left ventricular function and the development of constrictive pericarditis over the medium term in patients who had been treated surgically for subacute rupture of the left ventricle. Eleven patients with subacute rupture underwent surgery, of whom six were followed up over the medium term. A modest improvement in left ventricular systolic function was observed and there was no evidence of constrictive pericarditis. In conclusion, the surgical approach appears to be safe over the medium term and had no influence on left ventricular function. Nor did it lead to the development of constrictive pericarditis.

Causes of death in early MI survivors with persistent infarct artery occlusion: results from the Occluded Artery Trial (OAT)

AIMS

OAT randomised patients with an occluded infarct artery three to 28 days after myocardial infarction (MI). The study demonstrated that PCI did not reduce the occurrence of the primary composite endpoint of death, re-MI, and New York Heart Association class IV heart failure in comparison with patients assigned to optimal medical therapy alone (MED). In view of prior literature in similar cohorts showing fewer sudden cardiac deaths and less left ventricular (LV) remodelling, but excess re-MI with PCI, causes of death were analysed in more detail.

METHODS AND RESULTS

Stepwise Cox regression was used to examine baseline variables associated with causes of death. The immediate and primary cause of death did not differ between 1,101 PCI and 1,100 MED patients. One-year cardiovascular death rates were 3.8% for the PCI group, and 3.7% for the MED group, and 0.9% per year for the next four years in both groups. Five of six cases of cardiac rupture occurred in patients undergoing PCI.

CONCLUSIONS

In stable post-MI patients with occlusion of the infarct-related artery, PCI did not change the rate or cause of death. The observation that the majority of cardiac ruptures occurred in patients undergoing PCI deserves further investigation.

Survival without surgical repair of acute rupture of the right ventricular free wall

Rupture of the myocardial free wall is an infrequent complication of acute myocardial infarction. Unless it occurs in a space confined by pericardial adhesions, only surgical emergency repair of ruptured myocardium can prevent death. In this paper we report the case of an 81-year-old woman who was admitted to the emergency room with cardiac tamponade, resulting from inferolateral acute myocardial infarction and a subsequent rupture of the right ventricular free wall, with the formation of pericardial thrombus and effusion. The patient refused to undergo any surgical or invasive intervention, and therefore she was only treated conservatively. Nevertheless, her condition improved dramatically, as her blood pressure increased and echocardiography abnormalities almost disappeared. Follow-up echocardiography 7 months post discharge was unremarkable. We believe that this rare case emphasizes that in special circumstances, such as creation of a thrombus that prevents more blood from extravasating, free-wall rupture without surgical repair is compatible with long-term survival.

Critical care aspects in the management of patients with acute coronary syndromes

The spectrum of acute coronary syndromes (ACS) includes several clinical complexes that frequently cause critical instability in affected patients. This article focuses on several critical care aspects of these unstable ACS patients. The management of cardiogenic shock can be particularly challenging because the mechanical defects are varied in cause, severity, and specific treatment. Complications of fibrinolytic therapy are potentially deadly and arrhythmias are relatively common in the ACS patients. Discussions on the management of these problems should help the emergency physician more effectively to treat critically ill patients with ACS.

Delayed rupture of the left ventricle inferior wall: a diagnostic and surgical challenge

An acute rupture after an acute myocardial infarction with an unusually delayed presentation is described. The etiology, factors contributing to the delayed presentation, diagnosis, and management are discussed.

Myocardial infarction and left ventricular free wall rupture in a patient with a prior pericardiectomy

A 59-year-old man with an inferolateral myocardial infarction and cardiogenic shock was found to have extensive intrathoracic hemorrhage in communication with the left ventricle. His remote pericardiectomy precluded hemopericardium and tamponade, and permitted the establishment of an unusual diagnosis and subsequent closure of the site of myocardial perforation.

Cardiac Rupture in Embolic Myocardial Infarction after Implantation of a Valved Aortic Conduit

We report a case of an apical myocardial infarction complicated by left ventricular wall rupture due to coronary artery embolism four years after surgery of an acute type A dissection of an aortic aneurysm with implantation of a valved aortic conduit.

Complications of myocardial infarction

Echocardiography is a most useful bedside tool to help in the diagnosis and management of critically ill patients after acute myocardial infarction. In most instances, the mechanism of unexplained shock will be elucidated. Transesophageal echocardiography can further delineate the mechanical complications of myocardial infarction when the transthoracic echocardiogram may not be adequate. This article will focus on the mechanical complications of myocardial infarction in patients who most often present with cardiogenic shock or acute pulmonary edema. Each clinical entity is discussed, and illustrative echocardiograms are provided.

Subacute left ventricle free wall rupture after acute myocardial infarction: awareness of the clinical signs and early use of echocardiography may be life-saving

Left ventricular free wall rupture (LVFWR) is a fearful complication of acute myocardial infarction in which a swift diagnosis and emergency surgery can be crucial for successful treatment. Because a significant number of cases occur subacutely, clinicians should be aware of the risk factors, clinical features and diagnostic criteria of this complication. We report the case of a 69 year-old man in whom a subacute left ventricular free wall rupture (LVFWR) was diagnosed 7 days after an inferior myocardial infarction with late reperfusion therapy. An asymptomatic 3 to 5 mm saddle-shaped ST-segment elevation in anterior and lateral leads, detected on a routine ECG, led to an urgent bedside echocardiogram which showed basal inferior-wall akinesis, a small echodense pericardial effusion and a canalicular tract from endo to pericardium, along the interface between the necrotic and normal contracting myocardium, trough which power-Doppler examination suggested blood crossing the myocardial wall. A cardiac MRI further reinforced the possibility of contained LVFWR and a surgical procedure was undertaken, confirming the diagnosis and allowing the successful repair of the myocardial tear. This case illustrates that subacute LVFWR provides an opportunity for intervention. Recognition of the diversity of presentation and prompt use of echocardiography may be life-saving.

Sutureless off-pump repair of post-infarction left ventricular free wall rupture

Left ventricular free wall rupture after myocardial infarction has a high mortality. Suturing techniques of repair may be technically difficult and require cardiopulmonary bypass. We report a case of left ventricular rupture in a 47 year old man managed off pump employing a sutureless technique with Gelatine-Resorcin-Formalin glue and bovine pericardial patches.

Cardiac tamponade in the fibrinolytic era: analysis of >100,000 patients with ST-segment elevation myocardial infarction

BACKGROUND

Cardiac tamponade is a life-threatening complication of acute myocardial infarction (MI). Data on the incidence, risk factors, and outcome of tamponade in patients with acute MI in the fibrinolytic era are limited.

METHODS

Data from a combined clinical trials database of ST-segment elevation MI were used to evaluate the incidence of cardiac tamponade, baseline characteristics, and outcomes in patients with and without tamponade. Univariable and multivariable analyses assessed the relationship between patient characteristics and tamponade development, and the influence of tamponade on mortality.

RESULTS

Of 102,060 patients, 865 (0.85%) developed isolated cardiac tamponade during initial hospitalization. Patients with tamponade were older (median 71.9 vs 61.6 years, P < .001), were more likely to be female (54.0% vs 25.1%, P < .001), were more likely to have an anterior MI (61.9% vs 41.5%, P < .001), and had a longer time from symptom onset to reperfusion (median 3.5 vs 2.8 hours, P < .001) than those without tamponade. Multivariable analyses identified increasing age, anterior MI location, female sex, and increased time from symptom onset to treatment as significant independent predictors of tamponade. Patients with tamponade had an increased death rate at 30 days (hazard ratio 7.9, 95% CI 4.7-13.5).

CONCLUSION

Cardiac tamponade occurs in < 1% of patients with fibrinolytic-treated acute MI and is associated with increased 30-day mortality. Time from symptom onset to treatment strongly predicted the development of tamponade, underscoring the need for continued efforts to increase speed to treatment in acute MI.

Post-infarct left ventricular free wall rupture-not always a lethal complication of acute myocardial infarction

Post-myocardial infarction cardiac rupture is an important complication and cause of death in the period following myocardial infarction. It is rarely diagnosed before death. However, early diagnosis is crucial as successful treatment is possible with surgery. A successful outcome is sometimes compromised by difficult anatomy or an extensive infarct. Presentation, diagnosis and treatment of cardiac rupture is reviewed in this article, and is illustrated by five cases of cardiac rupture.

Cardiac rupture complicating myocardial infarction

Rupture of the ventricular free wall is a leading cause of death in patients with acute myocardial infarction (MI). There are a number of risk indicators that are associated with cardiac rupture, such as female gender, old age, hypertension, and first MI. Typical symptoms of cardiac rupture are recurrent or persistent chest pain, syncope, and distension of jugular veins. Electrocardiographic signs may include sinus tachycardia, new Q-waves in 2 or more leads, persistent or recurrent ST segment elevation, deviation of expected evolutionary T-wave pattern, and electromechanical dissociation in end-stage cases. Once patients at risk have been identified using clinical symptoms and electrocardiographic signs, a fast and sensitive diagnostic test to confirm cardiac rupture is transthoracic echocardiography (TTE). New insights in the etiology of subacute myocardial rupture suggests that defective cardiac remodeling may predispose the heart for rupture. The matrix metalloproteinase (MMP) system has been shown to play an important role in cardiac extracellular matrix (ECM) remodeling and cardiac rupture. Current therapy of cardiac rupture consists mainly of surgery, and conservative management with hemodynamic monitoring, prolonged bed rest, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors in selected cases.

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.

[Conservative management of a post infarction intramyocardial dissecting hematoma]

Intramyocardial dissecting hematoma is an infrequent complication of subacute myocardial infarction. Pathological findings consist of a cavity filled with blood, the outer wall of which is the myocardium and pericardium and the inner wall, which faces the ventricular cavity, is part of the myocardium and endocardium. There is scarce information on the subject and the management of these patients continues to be debated. However, there is a certain preference for surgical repair of the defect. Cases in which conservative treatment is a therapeutic option have been reported. We report the case of a patient with an intramyocardial dissecting hematoma after acute anterolateral myocardial infarction who was treated conservatively and achieved a satisfactory outcome in the intermediate-to-long term period.

Treatment strategies for postinfarction left ventricular free wall rupture: stabilization with peri-operative IABP and off-pump repair

BACKGROUND

Perioperative management of post-infarction left ventricular free wall rupture (LVFWR) is not clearly standardized and surgical repair is the only therapeutic option. Role of off-pump surgery and stabilization with perioperative intraaortic balloon pumping (IABP) were here analysed.

METHODS

Seven patients underwent surgery for LVFWR between 1990 and 2002. Clinical picture included electromechanical dissociation (3 patients) and sudden hypotension (4 patients). Except in one patient who was reanimated through femoro-femoral cardiopulmonary bypass, off-pump repair through on-lay patching technique was always performed. IABP was employed in the immediate postoperative period in five cases.

RESULTS

A satisfactory hemodynamic state was restored in all cases and there were no reoperations for bleeding or rerupture. Hospital survival was 100%. One patient underwent successful surgical myocardial revascularization two months after LVFWR. Two patients died at follow-up. The survivors present with good NYHA and CCS functional classes.

CONCLUSIONS

When the anatomy of the LVFWR is favourable, off-pump external patching repair proves a good choice. Postoperative IABP provides satisfactory hemodynamic support.

Role of contrast echocardiography in the assessment of myocardial rupture

Left ventricular free wall rupture is known to complicate acute myocardial infarction and is the second most common cause of inhospital mortality in this patient population. Contrary to widely held medical belief, this does not always result in immediate fatal pericardial tamponade with hemodynamic collapse. Up to 40% of such occurrences are subacute and may evolve over hours or even days. A high index of suspicion and accurate diagnostic tests are required to identify and treat these patients with emergent surgery. Echocardiography has emerged as an important diagnostic modality to identify this catastrophic condition. Although the literature has scattered reports on the role of transesophageal and transthoracic echocardiography in diagnosing free wall rupture, to date, only one report in the literature used ultrasound contrast agents to better delineate echocardiographic findings. We will present two cases in which echocardiography with use of intravenous ultrasound contrast agents was instrumental in helping to exclude rupture in one case and help identify rupture in another.

Oozing-type of left ventricular rupture treated under percutaneous cardiopulmonary support without surgical repair

A 65-year-old man was admitted to the National Defense Medical College Hospital for acute anterolateral myocardial infarction and cardiogenic shock. Emergency coronary angiography demonstrated occlusion of the proximal left anterior descending artery. Primary percutaneous transluminal coronary angioplasty (PTCA) was successfully performed with the support of intra-aortic balloon pumping (IABP) and medical treatment to stabilize the patient's blood pressure. On the second hospital day, the patient suffered cardiac tamponade. Pericardiocentesis showed bloody fluid and revealed that an oozing-type of left ventricular rupture had occurred after the myocardial infarction. Cardiogenic shock persisted after successful removal of the pericardial effusion. Although the heparinization required during percutaneous cardiopulmonary support (PCPS) can increase pericardial effusion, PCPS was initiated to correct the systemic hypoperfusion; a surgical team was on standby in case massive pericardial effusion resulted, but fortunately that did not occur, and cardiac function recovered. The patient was weaned successfully from PCPS and IABP and has remained in a satisfactory condition for over 1 year. PCPS contributed to the patient's recovery from cardiac shock and may have decreased the effusion from the oozing-type rupture by reducing ventricular wall tension.

Nature and progression of pericardial effusion in patients with a first myocardial infarction: relationship to age and free wall rupture

BACKGROUND

Left ventricular free wall rupture (FWR) usually develops within the first days of acute myocardial infarction (AMI) without warning, but it is uncertain whether a mild pericardial effusion might herald this complication.

METHODS

A 2-dimensional echocardiogram (2DE) was performed in patients with first AMI with (1149) or without (324) ST-segment elevation within 2 days. A second 2DE was performed 2 to 4 days later in 300 patients, 100 with and 200 without an initial mild PE (3-9 mm), and in those with initial moderate-severe PE (> or =10 mm) (MSPE) or who developed hypotension or died.

RESULTS

The first 2DE showed mild PE in 177 patients and MSPE in 51 patients, whereas a late (>2 days) MSPE occurred in 27 with a second routine 2DE, 15 (15%) with and 12 (6%) without initial mild PE (P =.01). Fourteen additional patients, 5 of 77 (6%) with and 9 of 1045 (1%) without initial PE, presented with hypotension and late MSPE (P <.002). Of 92 patients with MSPE, 90 had ST-segment elevation (98%), 60 had tamponade (65%), and 38 died of FWR or were operated on (41%). Results of pericardiocentesis performed in 64 patients were positive in 58, with hemopericardium in 57 (98%). Multivariant analysis showed mild PE on first 2DE and age of >60 years as the only independent predictors of late MSPE or late tamponade.

CONCLUSIONS

Mild PE within the first 2 days in patients aged >60 years with a first ST-segment elevation AMI is associated with an increased risk of late MSPE. Moreover, in this setting MSPE is most frequently associated with hemopericardium, and two thirds of these patients may develop tamponade/FWR.

Direct visualization of left ventricular free wall rupture by levocardiography

Two cases of left ventricular free wall rupture and one case of combined left ventricular free wall and ventricular septal rupture are described where ventriculography played a key role in diagnosis. In all three cases of patients with acute myocardial infarction, identification and localization of the defect was made by angiography. This report illustrates the safety and feasibility of ventriculography in patients with suspected cardiac rupture.

Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition

Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. We discuss a series of 11 patients with pathologically confirmed left atrial dissection who had been diagnosed previously by transesophageal echocardiography. Predisposing factors and surgical or pathologic findings were reviewed to identify the pathogenic mechanism and to explain the clinical course, hemodynamic disorder, and echocardiographic features. Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, and blunt chest trauma also could be related to its development. Transesophageal echocardiography identified a mobile intimal flap of the atrial wall that was creating a false chamber and allowed accurate diagnosis of prosthetic mitral valve function, endocarditis complications, and a left ventricular pseudoaneurysm after acute myocardial infarction. Color flow Doppler was particularly useful in identifying complications: communication between the false chamber and true left atria, permitting mitral regurgitation through the periannular route; development of atrial shunts; and severe tricuspid regurgitation caused by disruption of the anterior papillary muscle.

Survival following self-limited left ventricular free wall rupture during myocardial infarction. Management differences between patients with or without pseudoaneurysm formation

The clinical, angiographic and therapeutic features of eight patients who developed a left ventricular pseudoaneurysm (PA) after an acute myocardial infarction (AMI) and those of 25 who did not develop this complication following a medically managed left ventricular free wall rupture (FWR) were compared. These 25 patients were treated with pericardiocentesis, extended rest and strict blood pressure control. Most patients with FWR or PA had a first AMI and absence of overt heart failure. Both groups had a comparable age, frequency of systemic hypertension and extent of coronary disease. Pericardial effusion (> or =10 mm) was documented in all patients with FWR and in two of the three with PA with this information. Twenty four patients with FWR were hospitalized within the first 48 h (96%) but only three of those with PA (37.5%, P<0.002). Moreover, in patients with PA, a FWR was not suspected during AMI and, as opposed to those with FWR, they did not undergo a strict blood pressure control or a restriction of physical activity following AMI. Also, beta blockers were administered to 15 patients with FWR (60%) but to only one with PA (11%, P<0.02). Our findings suggest that failure to recognise a self limited FWR during AMI and to provide adequate control of blood pressure and physical exercise during the acute phase and the early weeks postinfarction, are likely to favor development of PA.

Successful repair of myocardial free wall rupture after thrombolytic therapy for acute infarction

BACKGROUND

Controversy exists regarding the timing of thrombolytic administration and rupture rate.

METHODS

Hospital records at St. Luke's-Roosevelt Hospital of the 4 study patients were reviewed and compared with those of 41 patients from a group of 537 patients concurrently admitted with a diagnosis of myocardial infarction (MI).

RESULTS

Four patients experienced ventricular free wall rupture after having a MI between November 17, 1993, and July 28, 1995. All received tissue plasminogen activator. In 1 patient, pericardial effusion associated with a pseudoaneurysm was discovered in the operating room. The 3 others developed clinical pericardial tamponade before surgery. All 4 patients survived and left the hospital on postoperative days 10, 11, 11, and 82, respectively. During this same time period, 537 patients were admitted with MI, 41 of whom died; the study's 4 patients were compared with these 41.

CONCLUSIONS

These data demonstrate that rupture of the ventricular free wall can occur early after thrombolytic therapy and may have a subacute course. Prompt diagnosis and surgery offer excellent chances of surviving this fatal condition.

Diagnosis of cardiac rupture with the use of contrast-enhanced echocardiography

We describe 3 patients with suspected subacute cardiac rupture in whom contrast-enhanced echocardiography played a key role in the diagnosis. In 2 patients, extravasation of the contrast material into the extracardiac space provided direct evidence of subacute cardiac rupture. Absence of this feature helped to exclude cardiac rupture with active hemorrhage into the pericardial space in the third patient. These 3 cases illustrate the safety and applicability of contrast echocardiography in patients with suspected cardiac rupture.

Cardiac rupture during exercise stress echocardiography: a case report

Stress echocardiography is widely used in the evaluation of coronary artery disease. Dobutamine stress echocardiography has been the preferred method, but many centers have adopted exercise stress echocardiography, which can visualize myocardial motion during physiologic stress testing. The complications of this method in the post-myocardial infarction period are the same as those identified in conventional exercise testing. We report a case of myocardial rupture in the postinfarction period during exercise stress echocardiography.

Potential utility of left heart contrast agents in diagnosis of myocardial rupture by 2-dimensional echocardiography

This case illustrates the use of intravenous injections of a contrast agent during 2-dimensional echocardiography in a patient with myocardial rupture after myocardial infarction. Intravenous injections of echocardiographic contrast agents may have potential use in the identification of intrapericardial hemorrhage after myocardial infarction caused by myocardial rupture or development of ventricular pseudoaneurysm.