Myocardial rupture: Difference between revisions
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===Etiology=== | ===Etiology=== | ||
*MI – “Softening” of myocardium<ref>Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.</ref> | *MI – “Softening” of myocardium<ref>Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.</ref> | ||
**1.7% of patients | **1.7% of MI patients | ||
**Typically 24-48h ( | **Typically occurs 24-48h post-MI (can be 3-5d if MI was untreated) | ||
**Rupture in the setting of MI is nearly 100% fatal<ref>Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.</ref> | |||
*Trauma – blunt and penetrating trauma | *Trauma – blunt and penetrating trauma | ||
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*Iatrogenic – Pacer wire placement<ref>Trigano JA, et al. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med. 1999; 28:836–40.</ref> | *Iatrogenic – Pacer wire placement<ref>Trigano JA, et al. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med. 1999; 28:836–40.</ref> | ||
** | **Tend to be small perforations which rarely lead to tamponade or hemodynamic consequences | ||
==Clinical Features== | ==Clinical Features== | ||
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==Workup== | ==Workup== | ||
*[[Ultrasound: Cardiac|Ultrasound]] | |||
**Pericardial effusion | |||
**Tamponade physiology (e.g. RV diastolic collapse) | |||
**Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow (due to the phenomenon of ventricular interdependence) | |||
*[[ECG]] | |||
**Tachycardia (bradycardia is ominous finding) | |||
**Normal or low voltage | |||
**Electrical alternans, low voltage QRS | |||
*[[CXR]] | |||
**Enlarged cardiac silhouette | |||
*[[Pulsus Paradoxus]] | |||
**>10mmHg change in systolic BP on inspiration | |||
*Direct visualization on thoracotomy (if indicated) | |||
==Management== | ==Management== | ||
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==Disposition== | ==Disposition== | ||
* | *Admit (likely directly to OR with cardiothoracic surgery) | ||
==See Also== | ==See Also== | ||
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==External Links== | ==External Links== | ||
==References== | ==References== | ||
Revision as of 00:19, 8 September 2016
Background
- Rupture includes defects in the atria, ventricles, or junctions of major vessels
Etiology
- MI – “Softening” of myocardium[1]
- 1.7% of MI patients
- Typically occurs 24-48h post-MI (can be 3-5d if MI was untreated)
- Rupture in the setting of MI is nearly 100% fatal[2]
- Trauma – blunt and penetrating trauma
- Penetrating trauma tends to affect RV
- RV 43%, LV 23%, RA 13%, LA 11%, Pericardium alone 10%[3]
- Infection – Endocarditis and myocardial necrosis[4]
- Rare
- Iatrogenic – Pacer wire placement[5]
- Tend to be small perforations which rarely lead to tamponade or hemodynamic consequences
Clinical Features
- Chest pain, shortness of breath
- Obvious chest injury
- Hypotension
- JVD
- Muffled heart sounds or new murmur or rub
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Workup
- Ultrasound
- Pericardial effusion
- Tamponade physiology (e.g. RV diastolic collapse)
- Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow (due to the phenomenon of ventricular interdependence)
- ECG
- Tachycardia (bradycardia is ominous finding)
- Normal or low voltage
- Electrical alternans, low voltage QRS
- CXR
- Enlarged cardiac silhouette
- Pulsus Paradoxus
- >10mmHg change in systolic BP on inspiration
- Direct visualization on thoracotomy (if indicated)
Management
- Pericardiocentesis in cases of tamponade
- Thoracotomy in traumatic cases
- Penetrating chest trauma with signs of life in the field
- Blunt chest trauma with signs of life lost in ED
- Definite treatment is emergency surgical repair
Disposition
- Admit (likely directly to OR with cardiothoracic surgery)
See Also
External Links
References
- ↑ Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.
- ↑ Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.
- ↑ Jin-mou Gao MD, et al. Penetrating cardiac wounds: Principles for surgical management. World Journal of Surgery. 2004; 28(10)1025-1029.
- ↑ Qizilbash AH and Schwartz CJ. False aneurysm of left ventricle due to perforation of mitral-aortic intervalvular fibrosa with rupture and cardiac tamponade: Rare complication of infective endocarditis. 1973; 32(1) :110-113.
- ↑ Trigano JA, et al. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med. 1999; 28:836–40.