Myocardial rupture

Background

  • Rupture includes defects in the atria, ventricles, or junctions of major vessels

Etiology

  • Myocardial infarction – “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

Emergent

Nonemergent

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

  1. Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.
  2. Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.
  3. Jin-mou Gao MD, et al. Penetrating cardiac wounds: Principles for surgical management. World Journal of Surgery. 2004; 28(10)1025-1029.
  4. 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.
  5. Trigano JA, et al. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med. 1999; 28:836–40.