Myocardial rupture

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Myocardial rupture is a laceration or tearing of the walls of the ventricles or atria of the heart, of the interatrial or interventricular septum, of the papillary muscles or chordae tendineae or of one of the valves of the heart. It is most commonly seen as a serious sequelae of an acute myocardial infarction (heart attack).

The most common cause of myocardial rupture is a recent myocardial infarction, with the rupture typically occurring three to five days after infarction. Other causes of rupture include cardiac trauma, endocarditis (infection of the heart),^[1][2] cardiac tumors, infiltrative diseases of the heart,^[1] and aortic dissection.

The incidence of myocardial rupture has decreased in the era of urgent revascularization and aggressive pharmacological therapy for the treatment of an acute myocardial rupture. However, the decrease in the incidence of myocardial rupture is not uniform; there is a slight increase in the incidence of rupture if thrombolytic agents are used to abort a myocardial infarction.^[3] On the other hand, if primary percutaneous coronary intervention is performed to abort the infarction, the incidence of rupture is significantly lowered.^[4] The incidence of myocardial rupture if PCI is performed in the setting of an acute myocardial infarction is about 1 percent.^[5]

Risk factors for rupture after an acute myocardial infarction include female gender, advanced age of the individual, and a low body mass index. Other presenting signs associated with myocardial rupture include a pericardial friction rub, sluggish flow in the coronary artery after it is opened, the left anterior descending artery being the cause of the acute MI,^[6] and delay of revascularization greater than 2 hours.

The prognosis of myocardial rupture is dependant on a number of factors, including which portion of the myocardium is involved in the rupture. In one case series, if myocardial rupture involved the free wall of the left ventricle, the mortality rate was 100 percent.^[7] Even if the individual survives the initial hemodynamic sequelae of the rupture, the 30 day mortality is still significantly higher than if rupture did not occur.^[7]

Symptoms of myocardial rupture are recurrent or persistent chest pain, syncope, and distension of jugular veins. Due to the acute hemodynamic deterioration associated with myocardial rupture, the diagnosis is generally made based on physical examination, changes in the vital signs, and clinical suspicion. The diagnosis can be confirmed with echocardiography.

Due to the acute hemodynamic deterioration associated with myocardial rupture, the diagnosis is generally made based on physical examination, changes in the vital signs, and clinical suspicion.

The diagnosis can be confirmed with echocardiography.

The treatment for myocardial rupture is supportive in the immediate setting and surgical correction of the rupture, if feasible. A certain small percentage of individuals do not seek medical attention in the acute setting survive. In this setting, it may be reasonable to treat the rupture medically and delay or avoid surgery completely, depending on the individual’s comorbid medical issues.

The treatment for myocardial rupture is supportive in the immediate setting and surgical correction of the rupture, if feasible. A certain small percentage of individuals do not seek medical attention in the acute setting survive. In this setting, it may be reasonable to treat the rupture medically and delay or avoid surgery completely, depending on the individual’s comorbid medical issues.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Myocardial ruptures can be classified as one of three types.

An abrupt slit-like tear that generally occurs within 24 hours of an acute myocardial infarction.

An erosion of the infarcted myocardium, which is suggestive of a slow tear of the dead myocardium. Type II ruptures typically occur more than 24 hours after the infarction occurred.

These ruptures are characterized by early aneurysm formation and subsequent rupture of the aneurysm.^[1]

Another method for classifying myocardial ruptures is by the anatomical portion of the heart that has ruptured. By far the most dramatic is rupture of the free wall of the left of right ventricles, as this is associated with immediate hemodynamic collapse and death secondary to acute pericardial tamponade. Rupture of the interventricular septum will cause a ventricular septal defect. Rupture of a papillary muscle will cause acute mitral regurgitation.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

The most common cause of myocardial rupture is a recent myocardial infarction, with the rupture typically occurring three to five days after infarction. Other causes of rupture include cardiac trauma, endocarditis (infection of the heart),^[1][2] cardiac tumors, infiltrative diseases of the heart,^[1] and aortic dissection.

Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

• Dexamethasone
• Prednisolone

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

The incidence of myocardial rupture has decreased in the era of urgent revascularization and aggressive pharmacological therapy for the treatment of an acute myocardial rupture. However, the decrease in the incidence of myocardial rupture is not uniform; there is a slight increase in the incidence of rupture if thrombolytic agents are used to abort a myocardial infarction.^[1] On the other hand, if primary percutaneous coronary intervention is performed to abort the infarction, the incidence of rupture is significantly lowered.^[2] The incidence of myocardial rupture if PCI is performed in the setting of an acute myocardial infarction is about 1 percent.^[3]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Risk factors for rupture after an acute myocardial infarction include female gender, advanced age of the individual, and a low body mass index. Other presenting signs associated with myocardial rupture include a pericardial friction rub, sluggish flow in the coronary artery after it is opened, the left anterior descending artery being the cause of the acute MI,^[1] and delay of revascularization greater than 2 hours.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Despite implantation of AICDs, there remains a high incidence of sudden death following ST elevation MI. This is due to the fact that not all sudden death is due to arrythmias in the period following ST elevation MI. Based upon autopsy findings, the relative frequency of various pathophysiologic events among 105 cases was as follows^[1]:

• 3 Index MIs in the first 7 days (2.9%)
• 28 Recurrent MIs (26.6%)
• 13 Cardiac ruptures (12.4%)
• 4 Pump failures (3.8%)
• 2 Other cardiovascular causes (stroke or pulmonary embolism; 1.9%)
• 1 Noncardiovascular cause (1%)
• 54 cases (51.4%) had no acute specific autopsy evidence other than the index MI and were thus presumed arrhythmic.

The relative contribution of arrhythmic death was lowest in the first month, while the relative contribution of recurrent MI or cardiac rupture was highest in the first month following ST elevation MI. After three months, however, the relative contribution shifted so that the proportion of cases attributable to arrhythmias was significantly higher than recurrent MI or rupture (P<0.0001).

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

The prognosis of myocardial rupture is dependant on a number of factors, including which portion of the myocardium is involved in the rupture. In one case series, if myocardial rupture involved the free wall of the left ventricle, the mortality rate was 100 percent.^[1] Even if the individual survives the initial hemodynamic sequelae of the rupture, the 30 day mortality is still significantly higher than if rupture did not occur.^[1]

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