Clinical course, timing of rupture and relationship with coronary recanalization therapy in 77 patients with ventricular free wall rupture following acute myocardial infarction

Left ventricular free wall rupture subsequent to early myocardial reinfarction after successful percutaneous transluminal coronary angiography

Left ventricular free wall rupture is a rare complication of acute myocardial infarction. Scarcely has a cardiac rupture subsequent to early reinfarction been reported. A left ventricular free wall rupture subsequent to reinfarction after successful percutaneous transluminal coronary angiography in a 78-year-old female is herein described.

Prognostic implications of PR-segment depression in inferior leads in acute inferior myocardial infarction

BACKGROUND

Concurrent atrial ischemia is usually overlooked in acute myocardial infarction (MI) due to its subtle electrocardiographic (ECG) changes, lack of clear-cut clinical picture, and prognostic significance. PR-segment depression in the inferior leads is a simplified ECG sign for detecting possible underlying atrial ischemia.

HYPOTHESIS

The purpose of this study was to document the incidence, clinical characteristics, and prognostic implications of this ECG sign in the setting of acute inferior MI.

METHODS

Demographics, clinical characteristics, and outcomes of 463 consecutive patients presenting with acute inferior MI were reviewed. The in-hospital ECG was examined by two independent reviewers. The results were then compared between those with and without ECG sign.

RESULTS

Profound PR-segment depression > or = 1.2 mm in inferior leads was found in 9 of 463 (1.9%) patients. Patients with atrial ischemia tended to present earlier (2.4 +/- 2.6 vs. 7.0 +/- 8.2 h, p = 0.000) and had a higher frequency of first-degree atrioventricular block (77.8 vs. 30.6%, p = 0.028) and supraventricular arrhythmias (55.5 vs. 20.2%, p = 0.022). Of greater importance, it was significantly associated with an increased rate of cardiac free-wall rupture (33.3 vs. 2.0%, p = 0.001) and in-hospital mortality (44.4 vs. 11.7%, p = 0.015).

CONCLUSION

Profound PR-segment depression > or = 1.2 mm in inferior leads was associated with a complicated hospital course and poor short-term outcome in acute inferior MI. These patients were at high risk for the development of atrioventricular block, supraventricular arrhythmias, and cardiac free-wall rupture.

Seasonal variation in mortality from myocardial infarction and haemopericardium. A postmortem study

BACKGROUND

Seasonal variation in the incidence of and mortality from myocardial infarction (MI) has been well recognised for many years. Haemopericardium (HP) is usually a fatal complication of MI. No data exist in the literature with regard to the seasonal variation in mortality from HP.

AIMS

To perform a necropsy based study to confirm seasonal variation in mortality from MI in a London population and to determine whether seasonal variation in mortality from HP can be established.

METHODS

Postmortem causes of death issued by several pathologists, working in two public London mortuaries over a five year period from 1999 to 2004 were analysed. Deaths caused by HP secondary to traumatic or iatrogenic causes were specifically excluded, as were deaths caused by HP secondary to bicuspid aortic valve and aortic dissection. The results were subdivided into winter (1 November to 31 March) and summer (1 April to 31 October).

RESULTS

In total, there were 2266 cases of MI and 135 cases of HP. Significantly more deaths from HP (83 of 135; 61.5%; p = 0.004) and MI (1051 of 2266; 46.4%; p = 0.016) occurred in the five month winter period. Furthermore, there was a significantly higher incidence of HP compared with MI during the winter (83/1051; 7.9%) than the summer (52/1215; 4.3%; p<0.001). There was no significant difference in the age or sex of patients dying in either the winter or summer.

CONCLUSION

There is seasonal variation in mortality from both MI and HP in the London population, as confirmed by a postmortem study.

[Contrast echocardiography for detection of incomplete rupture of the left ventricle after acute myocardial infarction]

Myocardial rupture is a major complication after acute myocardial infarction. With complete rupture of the free left ventricular wall cardiac tamponade occurs with fatal outcome in most cases. With partial rupture, however, hemorrhage is slower, allowing days or weeks for diagnosis. Survival of these patients strongly depends on early recognition of this complication followed by immediate surgical intervention. Echocardiography is the diagnostic tool of choice to detect myocardial rupture with consecutive hemopericardium but diagnosis remains difficult even if suspected. We describe the case of a patient with inferior infarction who presented with cardiogenic shock, echocardiographic signs of pericardial effusion and abnormal motion and myocardial irregularities of the inferior wall. With Doppler echocardiography no flow across the wall was detected. Left heart contrast echocardiography confirmed the diagnosis of suspected myocardial rupture by clear deliniation of the defect. Immediate surgical repair was successfully performed in this patient with favorable long-term outcome. Thus, echocardiography early after acute myocardial infarction is useful in detecting subsequent complications and the use of contrast echocardiography should be considered in suspected myocardial rupture.

Clinicopathological characteristics of 10 patients with rupture of both ventricular free wall and septum (double rupture) after acute myocardial infarction

Cardiac ruptures after myocardial infarction are classified as ventricular free wall ruptures (FWR), ventricular septal ruptures (VSR), and papillary muscle ruptures (PMR). A combination of any two types of rupture is called "ventricular double rupture;" (VDR) and shows a specific clinical course. 3,284 patients with acute myocardial infarction (AMI) were admitted to the CCU of our hospital between April, 1973 and December, 2001, and 10 patients (8 males and 2 female, aged 54 through 82 years) with VDR were clinicopathologically evaluated. All were diagnosed as VDR consisting of FWR and VSR. VDR was observed in 0.30% of all patients with AMI, in 3.0% of those with FWR, and in 16.1% of those with VSR. The infarct site was anteroseptal in 3 patients, anterolateral in 3, inferior in 3, and posterolateral in 1. Two patients with inferior infarction complicated RV infarction and a patient with posterolateral infarction had healed inferior infarction. The risk factors related to VDR were age, a history of hypertension, increased sympathetic tone to improve hemodynamic aggravation after perforation, cardiotonic agents, thrombolytic agents, delayed reperfusion, right ventricular volume overload by shunt and re-infarction. However, these factors might have played only a subsidiary role. The most important factor in VDR was the pathological findings. The site of septal perforation was the apex close to the septum-free wall junction in 9 patients and the site of rupture was also apical in 8 patients. Four patients already had VSR on admission to our CCU. FWR developed soon after VSR was demonstrated in 4 patients. FWR and VSR occurred simultaneously in one patient. These results suggest that VSR in the apical region is a precursor of VDR and requires the earliest surgical treatment. Surgical treatment was carried out in the operating room in 5 patients and 3 (60.0%) of them survived for 4 months or more. Two patients with rupture incidentally detected during operation for VSR were discharged and are still alive, though another one with free wall blow out rupture died 129 days after operation. Bedside thracotomy was performed in 3 patients and all of them died.