Left Ventricular Free Wall Rupture, Acute

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Sudden marked bradycardia and hypotension up to 2 weeks after acute myocardial infarction (MI)

• Cardiac arrest with electromechanical dissociation after acute MI

• Acute cardiac tamponade:

  • – Elevated jugular venous pressure

  • – Hypotension after acute MI

GENERAL CONSIDERATIONS

• Rupture of the free wall, interventricular septum, and papillary muscle is rare but may account for up to 15% of all deaths after an MI

• Delay in seeking treatment after MI is seen in these patients

• Sustained physical activity after an MI may precipitate this condition

• Role of prior use of corticosteroids and nonsteroidal anti-inflammatory drugs in promoting free wall rupture is controversial

• Common in elderly and women

• History of hypertension is common in affected patients

• Rupture usually involves anterior or lateral walls

• Usually involves a large infarct (> 20% of left ventricle [LV])

• Most common between 1 and 4 days after acute MI but may occur up to 3 weeks after MI

• Uncommon with thick ventricle

• Uncommon in patients with prior infarction and poor LV function

• Rupture leads to hemopericardium, cardiac tamponade, and death

• Survival depends on early recognition and emergent surgery

• Most common in LV; right ventricular rupture is uncommon; atrial rupture is rare

• Thrombolytics and percutaneous intervention have reduced the frequency of this complication

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Acute rupture: immediate death

• Subacute rupture:

  • – Nausea, diaphoresis

  • – Sharp chest pain secondary to pericardial irritation

  • – Shortness of breath

PHYSICAL EXAM FINDINGS

• Severe hypotension

• Tachycardia

• Soft heart sounds

• Pulmonary rales and dyspnea

DIFFERENTIAL DIAGNOSIS

• Acute ventricular septal rupture

• Acute mitral regurgitation

• Massive recurrent myocardial infarction

• Arrhythmic cardiac arrest

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• CBC

• Arterial blood gases

• Cardiac biomarkers

• Type and crossmatch for blood transfusion

ELECTROCARDIOGRAPHY

• ECG shows evolving MI pattern usually without acute changes

IMAGING STUDIES

• Emergency bedside transthoracic echocardiogram demonstrates ruptured wall and pericardial blood

• Contrast echocardiography may aid in detecting the rupture

TREATMENT

CARDIOLOGY REFERRAL

• Immediate referral to a cardiologist

HOSPITALIZATION CRITERIA

• All patients should be transferred to a coronary care unit before transfer to the operating room

DIAGNOSTIC PROCEDURES

• Percutaneous cardiopulmonary bypass in preparation for surgery

THERAPEUTIC PROCEDURES

• Immediate pericardiocentesis followed by emergency corrective surgery

• Intra-aortic balloon counterpulsation or percutaneous LV assist device to stabilize the patient for cardiac catheterization, if feasible

SURGERY

• Surgical repair: techniques to repair ...