Medical management of selected patients with left ventricular free wall rupture during acute myocardial infarction

Post-Myocardial Infarction (MI) Left Ventricular Free Wall Rupture Managed Conservatively

Left ventricular free wall rupture (LVFWR) is an uncommon but often fatal complication of acute myocardial infarction. LVFWR is managed with hemodynamic stabilization and is typically followed by surgical intervention with varying approaches depending on the type of LVFWR. A 78-year-old male with a history of coronary artery bypass graft (CABG) was admitted with ST-segment elevation myocardial infarction. Left heart catheterization showed complete occlusion of the saphenous vein graft to the 1st obtuse marginal artery. The patient was not a candidate for percutaneous coronary intervention or CABG. The patient later developed atrial fibrillation with a rapid ventricular response which was managed with beta blockers. Computed tomography pulmonary angiogram was done to rule out pulmonary embolus; however, it demonstrated findings of a lateral LVFWR. The patient was deemed a poor surgical candidate for cardiothoracic surgery, and the LVFWR was managed conservatively with metoprolol succinate and bed rest. He later required amiodarone and direct current cardioversion due to the recurrence of atrial fibrillation. Two months following the LVFWR, the patient remained stable with no apparent complications. In a certain subset of LVFWR patients, surgical management may not be possible given patient anatomy and other high-risk factors. In these cases, conservative management with bed rest and beta blockers and treatment of ventricular and atrial arrhythmias may be a viable therapeutic option.

Successful conservative treatment for left ventricular free wall rupture after acute myocardial infarction

Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days.

Sutureless repair of subacute left ventricular free wall rupture

Left ventricular free wall rupture (LVFWR) is one of the most lethal heart conditions where mortality rates reach 40% intraoperatively and 80% in hospital. A few days after the acute event, the rupture becomes subacute, and surgery is indicated to repair the frail myocardium. Despite the lack of strong evidence to support the efficacy of sutureless repair of subacute LVFWR in the literature, this technique has recently been gaining popularity with acceptable success rates. In this article, we present two techniques to repair the subacute LVFWR without using sutures: the direct glued-hemostatic patch technique and the glued pericardial patch technique. In both techniques, the healthy myocardium surrounding the infarcted zone is recruited, together with hemostatic materials, to seal the rupture. Moreover, we describe the clinical presentation of the acute and subacute LVFWR, peri-operative management, together with intra-operative tips and the advantages and disadvantages of each material used in these operations.

Surgical Treatment of Post-Infarction Left Ventricular Free-Wall Rupture: A Multicenter Study

BACKGROUND

Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes.

METHODS

Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post-acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality.

RESULTS

The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P < .001), cardiac arrest at presentation (P = .011), female sex (P = .044), and the need for preoperative extracorporeal life support (P = .003) were independent predictors for operative mortality.

CONCLUSIONS

Surgical repair of post-infarction LVFWR carries a high operative mortality. Female sex, preoperative left ventricular ejection fraction, cardiac arrest, and extracorporeal life support are predictors of early mortality.

A multicenter study on the clinical characteristics and risk factors of in-hospital mortality in patients with mechanical complications following acute myocardial infarction

Mechanical complications (MCs) following acute myocardial infarction (AMI), such as ventricular septal rupture (VSR), free-wall rupture (FWR), and papillary muscle rupture (PMR), are fatal. However, the risk factors of in-hospital mortality among patients with MCs have not been previously reported in Japan. The purpose of this study was to evaluate the prognostic factors of in-hospital mortality in these patients. The study cohort consisted of 233 consecutive patients with MCs from the registry of 10 facilities in the Cardiovascular Research Consortium-8 Universities (CIRC-8U) in East Japan between 1997 and 2014 (2.3% of 10,278 AMI patients). The authors conducted a retrospective observational study to analyse the correlation between the subtypes of MCs with in-hospital mortality, clinical data, and medical treatment. We observed a decreasing incidence of MC (1997-2004: 3.7%, 2005-2010: 2.1%, 2011-2014: 1.9%, p < 0.001). In-hospital mortality among patients with MCs was 46%. Thirty-three percent of patients with MCs were not able to undergo surgical repair due to advanced age or severe cardiogenic shock. In-hospital mortality among patients who had undergone surgical repair was 29% (VSR: 21%, FWR: 33%, PMR: 60%). In patients with MCs, hazard ratio for in-hospital mortality according to multivariate analysis of without surgical repair was 5.63 (95% CI 3.54-8.95). In patients with surgical repair, the hazard ratios of blow-out-type FWR (5.53, 95% confidence interval (CI) 2.22-13.76), those with renal dysfunction (3.11, 95% CI 1.37-7.05), and those receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) (3.79, 95% CI 1.81-7.96) were significantly high. Although primary percutaneous coronary intervention (PCI) is associated with decreased incidence of MCs, high in-hospital mortality persisted in patients with MCs that also presented with renal dysfunction and in those requiring VA-ECMO. Early detection and surgical repair of MCs are essential.

Left ventricular rupture: a rare complication and an unusual presentation

Myocardial infarction (MI) is a relatively common medical condition in the community. A rare complication of acute MI is left ventricular rupture (LV) rupture. This usually follows a transmural infarct. The incidence of this is 2%-4% and this usually happens within 3-7 days of MI. The anterolateral wall is involved in the majority of cases. Atypical presentations can occur several weeks after the initial event. Symptoms may mimic gastrointestinal disorder. The prognosis of this condition is very grim. However, with appropriate treatment, they can make an excellent recovery. The definitive treatment for this is surgical repair. We present the case of a 70-year-old man who had LV rupture and his clinical journey.

Cardiac Rupture Due to Reinfarction in the Early Phase of Apical Myocardial Infarction

A 72-year-old woman with hypertension, dyslipidemia, and diabetes mellitus presented to our hospital because of the sudden onset of chest pain. Emergency coronary angiography showed acute occlusion of the distal left anterior descending artery and coronary intervention with a drug-eluting stent was performed. Sudden cardiopulmonary arrest occurred on the sixth day of hospitalization, but coronary angiography showed no remarkable progression of the coronary artery diseases, including the site of stent implantation. An autopsy revealed that the cause of the sudden death was apical free wall rupture. In addition, the different timing of acute and sub-acute infarct findings were observed in the apical wall by histology, which indicated cardiac rupture was due to reinfarction at early phase of apical acute myocardial infarction. Although the rate of mechanical complications, including cardiac rupture, is decreasing in the era of primary coronary intervention, in addition to the well-known risk factors of cardiac rupture, the reinfarction of the culprit myocardial site in the early phase of acute myocardial infarction was considered as a possible risk factor of cardiac rupture.

Treatment strategies for post-infarction left ventricular free-wall rupture

Left ventricular free-wall rupture is one of the most fatal complications after acute myocardial infarction. Surgical treatment of post-infarction left ventricular free-wall rupture has evolved over time. Direct closure of the ventricular wall defect (linear closure) and resection of the infarcted myocardium (infarctectomy), with subsequent closure of the created defect with a prosthetic patch, represented the original techniques. Recently, less aggressive approaches, either with the use of surgical glues or the application of collagen sponge patches on the infarct area to cover the tear and achieve haemostasis, have been proposed. Despite such modifications in the therapeutic strategy and surgical treatment, however, postoperative in-hospital mortality may be as high as 35%. In extremely high-risk or inoperable patients, a non-surgical approach has been reported.

Comparison in Prevalence, Predictors, and Clinical Outcome of VSR Versus FWR after Acute Myocardial Infarction: The Prospective, Multicenter Registry MOODY Trial-Heart Rupture Analysis

BACKGROUND

Differences in the predictors between ventricular septal rupture (VSR) and free wall rupture (FWR) have not been fully studied. Data on the prevalence and clinical outcome of heart rupture are limited.

HYPOTHESIS

This study aimed to investigate heart rupture incidence and clinical results in patients with acute myocardial infarction (AMI).

METHODS

Of 9265 AMI patients in the MOODY registry between March 1999 and October 2016, a total of 146 were studied. The primary clinical endpoint was rupture prevalence and in-hospital mortality. Independent factors of heart rupture were analyzed using Cox proportional model and were compared between patients with VSR and those with FWR.

RESULTS

Of 9265 AMI patients, 146 (1.58%) patients had a heart rupture (FWR, 94 (1.02%)) and VSR (52 (0.56%)). All patients with FWR died during hospitalization, and in-hospital mortality was recorded in 37 (71.2%) patients with VSR, who had an extremely longer time delay from AMI onset to the first medical contact (FMC) (~20 h). FWR usually occurred in patients with ST-elevation myocardial infarction (STEMI) patients with a FMC ≥ 3 h, for whom primary reperfusion was not performed. Percutaneous repair at 1-2 weeks following AMI was associated with less mortality, and 9 of 38 patients who underwent non-primary reperfusion died post procedure.

CONCLUSION

This study demonstrated the importance of shortening FMC to prevent VSR and of early primary reperfusion in STEMI patients to reduce FWR. Urgent closure of rupture is necessary to reduce in-hospital and 1-year mortality.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.org, identifier: No. NCT03051048.

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.

Comparison of distinctive clinical and cardiac magnetic resonance features between ST elevation myocardial infarction patients with incomplete myocardial rupture and those with moderate to severe pericardial effusion

BACKGROUND

Whether patients with incomplete myocardial rupture (IMR) present distinctive clinical and cardiac magnetic resonance features from those with moderate-severe pericardial effusion (⩾10 mm (PE)) remains unknown.

METHODS

We compared the clinical, angiographic and cardiac magnetic resonance characteristics of nine patients with IMR (diagnosed angiographically and/or by cardiac magnetic resonance) with 29 with PE, and also with 38 without IMR or PE with evidence of transmural necrosis (reference group) matched for age, gender and year of admission.

RESULTS

Patients with IMR were younger than those with PE (p<0.001) but the two groups shared a higher rate of admission delay (78% and 41%) than those without IMR/PE (5%, p<0.001) and lower frequency of reperfusion therapy (44%, 55% and 100%, respectively, p<0.001). Thirteen patients with PE (45%) but only one IMR (11%) presented recurrent chest pain. IMR patients tended to present smaller infarct size at cardiac magnetic resonance (p=0.153 and 0.036) and number of segments with ⩾75% necrosis than PE patients and those without IMR/PE (p=0.098 and 0.029, respectively). Ten PE patients presented cardiac tamponade (35%). A control 2D-echocardiogram performed within two years in 71 patients (93%) documented a pseudoaneurysm in one PE and in one IMR patient.

CONCLUSIONS

IMR is generally silent and occurs in younger patients with smaller infarct size than those with PE although both present late and are often untreated with reperfusion therapy. These findings may warrant imaging assessment in ST elevation myocardial infarction patients with delayed admission, particularly in absence of reperfusion, to rule out an IMR.

Post-MI free wall rupture syndrome. Case report, literature review, and new terminology

Common clinical features of subacute rupture left ventricular free wall after acute ST segment elevation myocardial infarction are: (1) recurrent or persistent chest pain; (2) recurrent or persistent ST segment elevation; (3) hypotension. Integrating these signs into a syndrome can increase the clinician's awareness to the fatal complication.

Cardiac Rupture: New Features of the Old Disease

OBJECTIVES

Myocardial rupture is a rare but a fatal complication of acute myocardial infarction. During recent years, treatment strategies of acute myocardial infarction have changed. Primary percutaneous coronary interventions have replaced fibrinolytic therapy, thus reducing one of the major risk factors for myocardial rupture. In this work, we describe a group of patients who suffered myocardial rupture, none of whom were treated with thrombolytic therapy.

METHODS

The digital database of our hospital was searched for all patients who experienced myocardial rupture between 2008 and 2015. The demographic, clinical, angiographic and echocardiographic data of these patients were analyzed.

RESULTS

Out of 2,380 patients admitted with acute myocardial infarction, 12 (0.5%) developed myocardial rupture. The mean age was 78 years, and there were 7 males and 5 females. Ten patients already had pericardial effusion on admission. Seven patients underwent coronary angiography, whilst primary percutaneous intervention was performed in 4 patients. Six patients entered the operating room and all survived the procedure. All patients who were treated conservatively died due to rupture. Factors related to the treatment strategy were advanced age (≥ 90 years) and cognitive impairment.

CONCLUSIONS

The risk of myocardial rupture may be diminished by primary coronary intervention during myocardial infarction, but mortality remains high. An early, comprehensive echocardiographic examination and rapid surgery may contribute to improved survival.

Intramyocardial Dissection following Postinfarction Ventricular Wall Rupture Contained by Surrounding Postoperative Adhesions

Introduction. Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic dissection among the spiral myocardial fibers, its diagnosis is rarely established before the operation or death, and extremely few cases have been reported in the literature and none of these cases seem to have a history of previous cardiac surgery which makes our report unique. Case Presentation. A 61-year-old female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days. She had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. She was diagnosed with an acute inferoposterior myocardial infarction and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery. During the follow-up, she developed cardiogenic shock and a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular free wall rupture; then, she was taken in for emergency surgery. During the operation, a rupture zone and a wide intramyocardial dissecting area were detected. Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death. Conclusion. Pericardial adhesions might contain left ventricular rupture leading to intramyocardial dissection.

Left ventricular pseudoaneurysm formation: Two cases and review of the literature

Left ventricular wall rupture (LVWR) comprises a complication of acute myocardial infarction (AMI). Acute LVWR is a fatal condition, unless the formation of a pseudoaneurysm occurs. Several risk factors have been described, predisposing to LVWR. High index of suspicion and imaging techniques, namely echocardiography and computed tomography, are the cornerstones of timely diagnosis of the condition. As LVWR usually leads to death, emergency surgery is the treatment of choice, resulting in significant reduction in mortality and providing favorable short-term outcomes and adequate prognosis during late follow-up. Herein, we present two patients who were diagnosed with LVWR following AMI, and subsequent pseudoaneurysm formation. In parallel, we review the aforementioned condition.

Is it ever possible to treat left ventricular free wall rupture conservatively?

A best evidence topic was written according to a structured protocol. The question addressed was whether conservative or surgical management would result in better outcomes in patients presenting with left ventricular free wall rupture (LVFWR) following acute myocardial infarction. Surgical techniques involved were infarctectomy + patch repair, suturing of an overlay patch to the defect, patch-and-glue repair and so on, on or off cardiopulmonary bypass. A total of 210 papers were found using the reported searches, of which 10 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results were tabulated. The studies found analysed the outcome related to conservative and surgical approaches plus the effects of cardiopulmonary bypass circuit and systemic heparinization on bleeding around the peri-infarct myocardial tissue in the surgical group. Most of the data available were either case reports or retrospective analysis of the cohort using the 2 techniques and showed that ruptures present in different sites and sizes. Patients with a milder form of LVFWR can be managed conservatively, but the irony is that it is difficult to identify these patients, because a small oozing-type rupture can increase in size and lead to large defect with sudden arrest of the patient and most probably death. More recently with patch-and-glue techniques, avoiding cardiopulmonary bypass, short- and mid-term survival rates have improved to 60-80% in studies of consecutive patients' series, which illustrates real-life experiences.

Intra-pericardial thrombin injection for post-infarction left ventricular free wall rupture

Left ventricular free wall rupture (LVFWR) is a fatal complication of acute myocardial infarction. Different modalities of treatment were previously described, including surgical intervention and medical treatment. We report a case treated with intra-pericardial thrombin injection that gave a favourable outcome for a patient who presented with LVFWR and cardiac tamponade, following acute myocardial infarction.

Successful therapy of ventricular rupture by percutaneous intrapericardial instillation of fibrin glue: a case report

Rupture of the ventricular myocardium is an often lethal complication after myocardial infarction. Due to the dramatic hemodynamics and the short time frame between ventricular rupture and surgical closure of the defect, additional therapeutic strategies are needed. Here we report the successful therapy of ventricular rupture by percutaneous intrapericardial instillation of fibrin glue in a 72-year-old male patient with postinfarct angina secondary to anterior myocardial infarction.

Adjuvant Role of CT in the Diagnosis of Post-Infarction Left Ventricular Free-Wall Rupture

Left ventricular free wall rupture is usually a catastrophic mechanical complication of myocardial infarction. Risk factors include advanced age, female gender and absence of prior infarction. The vast majority of patients succumb rapidly due to cardiac tamponade and electromechanical dissociation. Expedited and accurate diagnosis can improve the chances of survival. Echocardiography has been advocated as the gold standard for diagnosis, but other imaging modalities can provide valuable information in these patients. We present the case of a patient who presented with cardiogenic shock, in which the definitive diagnosis of a left ventricular free wall rupture was accomplished by CT scan with intravenous contrast.

Donepezil, anti-Alzheimer's disease drug, prevents cardiac rupture during acute phase of myocardial infarction in mice

BACKGROUND

We have previously demonstrated that the chronic intervention in the cholinergic system by donepezil, an acetylcholinesterase inhibitor, plays a beneficial role in suppressing long-term cardiac remodeling after myocardial infarction (MI). In comparison with such a chronic effect, however, the acute effect of donepezil during an acute phase of MI remains unclear. Noticing recent findings of a cholinergic mechanism for anti-inflammatory actions, we tested the hypothesis that donepezil attenuates an acute inflammatory tissue injury following MI.

METHODS AND RESULTS

In isolated and activated macrophages, donepezil significantly reduced intra- and extracellular matrix metalloproteinase-9 (MMP-9). In mice with MI, despite the comparable values of heart rate and blood pressure, the donepezil-treated group showed a significantly lower incidence of cardiac rupture than the untreated group during the acute phase of MI. Immunohistochemistry revealed that MMP-9 was localized at the infarct area where a large number of inflammatory cells including macrophages infiltrated, and the expression and the enzymatic activity of MMP-9 at the left ventricular infarct area was significantly reduced in the donepezil-treated group.

CONCLUSION

The present study suggests that donepezil inhibits the MMP-9-related acute inflammatory tissue injury in the infarcted myocardium, thereby reduces the risk of left ventricular free wall rupture during the acute phase of MI.

The first clinical pilot study of intravenous adrenomedullin administration in patients with acute myocardial infarction

Adrenomedullin (AM) is a 52-amino-acid vasodilator peptide that was originally isolated from human pheochromocytoma. In the previous experimental study with rat ischemia/reperfusion model, AM reduced infarct size and inhibited myocyte apoptosis. AM also suppressed the production of oxygen-free radicals. The present study was designed to evaluate the feasibility of intravenous administration of AM in patients with acute myocardial infarction. We studied 10 patients with first acute myocardial infarction [male to female ratio: 9 to 1, age: 65 ± 9 (mean ± SD) years, peak creatine phosphokinase level: 4215 ± 1933 (SD) U/L], who were hospitalized within 12 hours of symptom onset. Proceeding reperfusion therapy, AM infusion was initiated and continued at concentration of 0.0125-0.025 μg·kg·min for 12 hours. Follow-up coronary angiography and left ventriculography were performed at 3 months. Cardiac magnetic resonance was examined at 1 month and 3 months after AM therapy. During infusion of AM, hemodynamics kept stable except 2 patients. Wall motion index in the infarct area at 3 months was significantly improved compared with that at baseline, and infarct size evaluated by cardiac magnetic resonance was significantly decreased at 3 months. In conclusion, intravenous administration of AM, which possesses a variety of potential cardiovascular protective actions, can be adjunctive to percutaneous coronary intervention.

Acute left ventricular rupture following posterior wall myocardial infarction

Free wall rupture, the most fearful complication of myocardial infarction, mostly attacks anterior walls. Acute rupture is characterized by rapid development of mechanical arrest accompanied with bradyarrhythmia or electromechanical dissociation. The majority of patients succumb to death as the result of cardiac tamponade. Risk factors are advanced age, female gender, the first-time myocardial infarction, hypertension, and ST-segment elevation. We report a rare case of posterior wall myocardial infarction complicated with left ventricular rupture initially presenting with junctional escape rhythm.

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.

Left ventricular free-wall rupture in acute myocardial infarction : a blow-out type case

One of the most serious complications following acute myocardial infarction is left ventricular free-wall rupture (LVFWR). There are two different types of anatomical-pathological rupture: (i) the 'oozing' type, characterized by perforation, which allows enough time for diagnosis and surgery; and (ii) the blow-out type characterized by rapid, irreversible, electromechanical dissociation, shock and death within a few minutes due to massive haemorrhages into the pericardial cavity. Consequently, the prevention of LVFWR could save more lives than treatment, and early recognition and diagnosis could be more beneficial than potentially life-saving therapeutic intervention. A better understanding of the pathogenesis of LVFWR could improve the survival rate of patients with LVFWR. This article reports a blow-out type case of LVFWR, together with a review of the literature including risk factors, pathophysiology, clinical manifestation, diagnosis, surgical treatment and adjunctive therapies.

Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period

BACKGROUND

Possible changes in the incidence and outcome of cardiac rupture in patients with ST-elevation myocardial infarction over a long period of time have not been investigated.

METHODS AND RESULTS

The incidence of cardiac rupture in ST-elevation myocardial infarction patients and its mortality rate were investigated during a 30-year period divided into 5 intervals (1977 to 1982, 1983 to 1988, 1989 to 1994, 1995 to 2000, and 2001 to 2006). Of a total of 6678 consecutive patients, 425 experienced a free wall rupture (280 with cardiac tamponade: 227 with electromechanical dissociation and 53 with hypotension) or a septal rupture (145). After the exclusion of referrals from other centers (n=44), the incidence of definite cardiac rupture (septal rupture, anatomic evidence of free wall rupture, or electromechanical dissociation) declined progressively (6.2% in 1977 to 1982 to 3.2% in 2001 to 2006; P<0.001) in parallel with a progressive use of reperfusion therapy (0% to 75.1%; P<0.001). In addition, among patients with cardiac rupture, there was a progressive fall in the rate of death (94% to 75%; P<0.001) despite a trend toward increasing age (66+/-8 to 75+/-8 years; P<0.054) in conjunction with better control of systolic blood pressure at 24 hours (130+/-24 versus 110+/-18 mm Hg; P<0.001); an increased use of reperfusion therapy (0% to 59%; P<0.001), beta-blockers (0% to 45%; P<0.001), angiotensin-converting enzyme inhibitors (0% to 38%; P<0.001), and aspirin (0% to 96%; P<0.001); and a lower use of heparin (99% to 67%; P<0.001).

CONCLUSIONS

The decline in the incidence in cardiac rupture and its rate of death over the last 30 years appears to be associated with the increasing use of reperfusion strategies and adjunct medical therapy.

Outcome of percutaneous intrapericardial fibrin-glue injection therapy for left ventricular free wall rupture secondary to acute myocardial infarction

Left ventricular free wall rupture (LVFWR) is a fetal complication of acute myocardial infarction. This study was conducted to test the feasibility of percutaneous intrapericardial fibrin-glue injection therapy (PIFIT) for LVFWR after acute myocardial infarction and to assess its clinical outcome. From January 2000 to December 2004, LVFWR was confirmed by echocardiography in 22 patients. Thirteen patients showing abrupt hemodynamic collapse failed to recover from resuscitation maneuvers and died <2 hours after LVFWR. The remaining 9 patients (5 women, mean age 73 +/- 10 years) underwent PIFIT. Pericardiocentesis was performed from the subxiphoid process, and a 6Fr pigtail catheter was introduced into the pericardial space. After bloody fluid was drained from the catheter, the fibrin glue was injected into the pericardial space. There were no complications relating to pericardiocentesis and PIFIT. One patient underwent surgical repair on the day of PIFIT because of uncontrollable bleeding from pericardial drainage. In-hospital death as a result of rerupture occurred in 2 patients on days 4 and 7 after PIFIT. Echocardiography during follow-up revealed no evidence of pseudoaneurysm or left ventricular restriction. On follow-up at a median of 4.0 years (interquartile range 3.1 to 4.8), 1 noncardiac death occurred at 3.3 months. The other 5 patients were free of cardiovascular events and in New York Heart Association functional class I. In conclusion, PIFIT is a simple, effective, and less invasive technique for the management of LVFWR and thus can be an alternative to surgical repair for LVFWR after acute myocardial infarction.

Left ventricular oozing rupture following acute myocardial infarction

We describe the case of an 85-year-old woman in whom pericardiocentesis, prolonged bed rest and blood pressure control were performed without surgery to successfully treat an oozing-type myocardial rupture due to myocardial infarction.

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.

Incomplete myocardial rupture following inferior myocardial infarction: a case report

In an era of early and invasive therapeutic approaches, myocardial rupture has become an uncommon complication of myocardial infarction. While septal wall rupture most often leads to devastating haemodynamic consequences, free wall rupture is usually fatal. We report a case of a 48-year-old man in whom an incomplete myocardial rupture located in the inferior part of the interventricular septum was promptly detected during the acute phase of an inferior myocardial infarction treated by early percutaneous coronary angioplasty. A conservative rather than a surgical approach was decided with a favourable short-term outcome.

Free-wall rupture of the myocardium following infarction: a changing clinical portrait in the reperfusion era: a case report

Free wall rupture of the myocardium is an important complication and major cause of death following acute transmural (ST segment elevation) myocardial infarction. Pathologic changes on a cellular level may combine with mechanical stressors to weaken the myocardium postinfarction. Risk factors for myocardial rupture include advanced age, female gender, prior hyper-tension, first myocardial infarction, late presentation, lack of collateral blood flow, and persisting chest pain and ST segment elevations. Thrombolytic therapy does not increase risk of rupture when given early in myocardial infarction, but late thrombolytic therapy may heighten risk. Primary percutaneous coronary intervention for acute myocardial infarction has reduced the incidence of myocardial rupture compared to thrombolytic therapy. This advantage likely can be ascribed to higher rates of immediate reperfusion with catheter techniques, as well as to the avoidance of thrombolytic-mediated hemorrhagic transformation of the infarction zone. Careful regulation of blood pressure and pulse using nitrates and beta-adrenergic blockers may mitigate the tendency toward myocardial rupture. Early and accurate diagnosis based on clinical and echocardiographic evidence can lead to successful surgical treatment.

Contained myocardial rupture: a variant linking complete and incomplete rupture

Myocardial rupture is an uncommon complication of myocardial infarction, often with devastating haemodynamic consequences. Although rupture is usually fatal, when patients do survive, the majority present with a pseudoaneurysm in which the rupture is sealed by a haematoma on the epicardial surface of the heart. Cases in which all myocardial layers are dissected except the epicardium or visceral pericardium have been included under this subheading. The authors describe such a case and suggest the pathological description of a "contained myocardial rupture". This link between complete and incomplete myocardial rupture may allow a more conservative management approach to be pursued.

[Mechanical complications of acute myocardial infarction]

Rupture of the left ventricular myocardium during the course of an acute myocardial infarction may affect the free wall, the interventricular septum, or the papillary muscles. When a rupture occurs, it is referred to as a mechanical complication of acute myocardial infarction. All mechanical complications may lead to cardiogenic shock. However, the location of the rupture can often be suspected clinically. To confirm the diagnosis, echocardiography must be performed. Since the advent of thrombolytic therapy and percutaneous coronary intervention, the incidence of mechanical complications has declined. Even though mortality remains high, their recognition is important since survivors may have an excellent long-term prognosis. The cases convey two main messages: 1) Mechanical complications must be carefully searched for in any patient with an acute coronary syndrome and signs of cardiogenic shock and/or a systolic murmur. 2) Aggressive and timely medical and surgical treatment should be provided even though in a substantial proportion of these patients prognosis may be dismal.

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.

Acute myocardial infarction: disposition to the operating room?

Given their low incidence, mechanical complications of AMI represent a diagnostic and therapeutic challenge for the EP. When the panoply of medical interventions has reached its limitation, surgical treatment plays a role in the management of the patient who has AMI. For patients who have CS and severe compromise of myocardial reserve, surgical intervention might represent the only means of restoring blood flow to the myocardium. For patients who have mechanical complications, correction of the defect before the onset of terminal organ failure might provide long-term survival.

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.

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.

Sutureless patch technique for postinfarction left ventricular rupture

BACKGROUND

Left ventricular free wall rupture is an uncommon but catastrophic event after myocardial infarction and is associated with a high mortality. After prompt diagnosis some patients may be salvaged with immediate surgical intervention. Surgical techniques used to seal the rupture vary, as few surgeons have experience with this pathologic process. We report our experience using a sutureless patch technique to treat this entity.

METHODS

A review of 6 consecutive patients during an 8-year period who were referred to one cardiac unit with postinfarction left ventricular rupture was conducted.

RESULTS

There were 3 men and 3 women with an average age of 71.8 years. All were hemodynamically unstable, and 4 were in electromechanical dissociation. Echocardiography confirmed the diagnosis in 5 patients, and cardiac catheterization had been performed in 4 before rupture. All patients were treated promptly with fluid, inotropic agents, and, if needed, cardiopulmonary resuscitation and pericardiocentesis. Resuscitation was continued in the operating room, and the myocardial tear was sealed with a generous patch of unsupported felt secured to the heart with cyanoacrylate glue. Coronary artery bypass grafting was performed in 3 patients if the anatomy was known. All patients survived to the intensive care unit. One death occurred as a result of severe neurologic injury. Five patients were discharged from the hospital, and all were alive 2 months to 7.5 years after operation.

CONCLUSIONS

A sutureless patch technique for the treatment of postinfarction rupture is simple, effective, and associated with a favorable outcome.

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.

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.