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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 the ventricle include direct suture or patch to cover the ventricular perforation

  • Coronary artery bypass graft as ...

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