Myocardial Rupture Treatment & Management

  • Author: Jamshid Shirani, MD; Chief Editor: Eric H Yang, MD   more...
 
Updated: Dec 2, 2011
 

Medical Care

Early surgical intervention is essential for the treatment of myocardial rupture. Medical therapy may be used in some cases to stabilize the patient during the time needed to assemble the surgical team.

In less severe cases of papillary muscle rupture, vasodilators should be started to decrease afterload in an attempt to stabilize patients before surgery. This is often accomplished with intravenous nitroprusside. In severe cases, insertion of an intraaortic balloon pump may be necessary.

In VSD, intravenous inotropic agents, vasodilators, and diuretics can be used to increase cardiac output and decrease afterload. Insertion of an intraaortic balloon pump is helpful.

Rapid fluid administration to increase preload and inotropic drugs to improve cardiac output can be useful in case of free-wall rupture while patient is being transferred to the operating room.

Next

Surgical Care

In most patients, immediate surgery is necessary and should not be delayed by attempts to stabilize the patient medically.

Mitral valve replacement generally is necessary for papillary muscle rupture.

Surgical therapy for free-wall rupture includes resection of the infarcted area and closure of the rupture zone with Teflon or Dacron patches or with the use of biological glues. Successful off-pump surgery (without the use of cardiopulmonary bypass) has been reported.

VSDs can be closed directly or by placement of a patch, depending on the size of the defect and the timing of the surgery.

Pseudoaneurysms carry a high risk of rupture, even though long-term survivors have been reported. Therefore, surgical repair is recommended, even in asymptomatic patients. Surgical repair is similar to ventricular rupture.

Coronary artery bypass surgery is often needed as part of the treatment of patients with mechanical complications of AMI undergoing surgical correction. This is especially true for patients with VSD.

A recent report of the Society of Thoracic Surgery National Cardiac Database has indicated that patients undergoing coronary artery bypass surgery for cardiogenic shock following acute myocardial infarction have a 19% operative mortality. This increases to 31% for those also requiring mitral valve replacement and to 58% if repair of a ruptured ventricular septum is required.[3]

Previous
Next

Consultations

Immediate consultation with a cardiothoracic surgeon is indicated in all cases of myocardial rupture.

Previous
Next

Diet

Nothing by mouth (NPO) is indicated.

Previous
Next

Activity

Complete bed rest is indicated.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Jamshid Shirani, MD  Director of Cardiology Fellowship Program, Director of Echocardiography Laboratory, St Luke's Hospital and Health Network

Jamshid Shirani, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Echocardiography, and Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Coauthor(s)

Jamshid Alaeddini, MD, FACC  Clinical Cardiac Electrophysiologist, Inland Cardiology Associates

Jamshid Alaeddini, MD, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association

Disclosure: Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; St. Jude Honoraria Speaking and teaching; Reliant Honoraria Speaking and teaching

Alessandra Brofferio, MD  Fellow, Department of Cardiovascular Medicine, Geisinger Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric Vanderbush, MD, FACC  Chief, Department of Internal Medicine, Division of Cardiology, Harlem Hospital Center; Clinical Assistant Professor of Cardiology, Columbia University College of Physicians and Surgeons

Eric Vanderbush, MD, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Marschall S Runge, MD, PhD  Charles and Anne Sanders Distinguished Professor of Medicine, Chairman, Department of Medicine, Vice Dean for Clinical Affairs, University of North Carolina at Chapel Hill School of Medicine

Marschall S Runge, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Southern Society for Clinical Investigation, and Texas Medical Association

Disclosure: Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Orthoclinica Diagnostica Consulting fee Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD  Associate Professor of Medicine, Director of Interventional Cardiology Fellowship Program, Henry Ford Hospital

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

References

  1. Javaid MM, Grigoriou A, Katsianos D, Kon SP. NEPHROTIC AND ANTI-PHOSPHOLIPID SYNDROMES: MULTISYSTEM CONDITIONS ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION IN YOUNG PATIENTS. J Ren Care. Sep 14 2011;[Medline].

  2. Suzuki M, Enomoto D, Seike F, Fujita S, Honda K. Clinical Features of Early Myocardial Rupture of Acute Myocardial Infarction. Angiology. Nov 8 2011;[Medline].

  3. Rajendra H. Mehta, MD, MS; Joshua D. Grab, MS; Sean M. O'Brien, PhD; Donald D. Glower, MD;Constance K. Haan, et al. Clinical characteristics and in-hospital outcomes of patients with cardiogenic shock undergoing coronary artery bypass surgery: insights from the Society of Thoracic Surgeons National Cardiac Database. Circulation. 2/2008;117:876-885. [Medline]. [Full Text].

  4. Barnard SP, Kitching PA, Kulatilake EN. Right ventricle rupture after coronary surgery. Cardiovas Surg. Dec 1994;2 (6):723-24. [Medline].

  5. Birnbaum Y, Chamoun AJ, Anzuini A, et al. Ventricular free wall rupture following acute myocardial infarction. Coron Artery Dis. Sep 2003;14(6):463-70. [Medline].

  6. Birnbaum Y, Fishbein MC, Blanche C, Siegel RJ. Ventricular septal rupture after acute myocardial infarction. N Engl J Med. Oct 31 2002;347(18):1426-32. [Medline].

  7. Brodie BR, Stuckey TD, Hansen CJ, et al. Timing and mechanism of death determined clinically after primary angioplasty for acute myocardial infarction. Am J Cardiol. Jun 15 1997;79(12):1586-91. [Medline].

  8. Frances C, Romero A, Grady D. left ventricular pseudoaneurysm. J Am Col Cardiol. Sep 1998;32 (3):557-61. [Medline].

  9. Geist M, Gilon D, Gotsman MS, Hasin Y. Cardiac rupture during coronary angioplasty. Eur Heart J. Jul 1993;14(7):1002-3. [Medline].

  10. Hayashi T, Hirano Y, Takai H, et al. Usefulness of ST-segment elevation in the inferior leads in predicting ventricular septal rupture in patients with anterior wall acute myocardial infarction. Am J Cardiol. Oct 15 2005;96(8):1037-41. [Medline].

  11. Helmy TA, Nicholson WJ, Lick S, Uretsky BF. Contained myocardial rupture: a variant linking complete and incomplete rupture. Heart. Feb 2005;91(2):e13. [Medline].

  12. Honan MB, Harrell FE Jr, Reimer KA, et al. Cardiac rupture, mortality and the timing of thrombolytic therapy: a meta-analysis. J Am Coll Cardiol. Aug 1990;16(2):359-67. [Medline].

  13. Laws HL. The broken heart. Am Surg. Jun 1998;64 (6):485-92. [Medline].

  14. March KL, Sawada SG, Tarver RD, et al. Current concepts of left ventricular pseudoaneurysm: pathophysiology, therapy, and diagnostic imaging methods. Clin Cardiol. Sep 1989;12(9):531-40. [Medline].

  15. May AK, Patterson MA, Rue LW 3rd, et al. Combined blunt cardiac and pericardial rupture: review of the literature and report of a new diagnostic algorithm. Am Surg. Jun 1999;65(6):568-74. [Medline].

  16. Minami H, Mukohara N, Obo H, et al. Papillary muscle rupture following acute myocardial infarction. Jpn J Thorac Cardiovasc Surg. Aug 2004;52(8):367-71. [Medline].

  17. Molajo AO, McWilliam L, Ward C, Rahman A. Cardiac lymphoma: an unusual case of myocardial perforation--clinical, echocardiographic, haemodynamic and pathological features. Eur Heart J. May 1987;8(5):549-52. [Medline].

  18. Neiman J, Hui WK. Posteromedial papillary muscle rupture as a result of right coronary artery occlusion after blunt chest injury. Am Heart J. Jun 1992;123 (6):1694-9. [Medline].

  19. Nishiyama K, Okino S, Andou J, et al. Coronary angioplasty reduces free wall rupture and improves mortality and morbidity of acute myocardial infarction. J Invasive Cardiol. Oct 2004;16(10):554-8. [Medline].

  20. Ohri SK, Nihoyannopoulos P, Taylor KM, Keogh BE. Angiosarcoma of the heart causing cardiac rupture: a rare cause of hemopericardium. Ann Thorac Surg. Feb 1993;55(2):525-8. [Medline].

  21. Okino S, Nishiyama K, Ando K, Nobuyoshi M. Thrombolysis increases the risk of free wall rupture in patients with acute myocardial infarction undergoing percutaneous coronary intervention. J Interv Cardiol. Jun 2005;18(3):167-72. [Medline].

  22. Perchinsky MJ, Long WB, Hill JG. Blunt cardiac rupture. The Emanuel trauma center experience. Arch Surg. Aug 1995;130 (8):852-6. [Medline].

  23. Shirani J, Berezowski K, Roberts WC. Out-of-hospital sudden death from left ventricular free wall rupture during acute myocardial infarction as the first and only manifestation of atherosclerotic coronary artery disease. Am J Cardiol. Jan 1994;73(1):88-92. [Medline].

  24. Smedira NG, Zikri M, Thomas JD, et al. Blunt traumatic rupture of a mitral papillary muscle head. Ann Thorac Surg. May 1996;61(5):1526-8. [Medline].

  25. Symbas PN. Traumatic heart disease. Curr Probl Cardiol. Aug 1991;16(8):537-82. [Medline].

  26. Topol EJ. Acute coronary syndromes. New York, NY: Marcel Dekker; 1998:. 269-325.

  27. Ueda S, Ikeda U, Yamamoto K, et al. C-reactive protein as a predictor of cardiac rupture after acute myocardial infarction. Am Heart J. May 1996;131(5):857-60. [Medline].

  28. Vargas-Barron J, Molina-Carrion M, Romero-Cardenas A, et al. Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction. Am J Cardiol. May 15 2005;95(10):1153-8. [Medline].

  29. Wehrens XH, Doevendans PA. Cardiac rupture complicating myocardial infarction. Int J Cardiol. Jun 2004;95(2-3):285-92. [Medline].

  30. Weinstein L, Brusch JL. Infective endocarditis. London, UK: Oxford University Press; 1996:. 176-7.

  31. Yip HK, Fang CY, Tsai KT, et al. The potential impact of primary percutaneous coronary intervention on ventricular septal rupture complicating acute myocardial infarction. Chest. May 2004;125(5):1622-8. [Medline].

  32. Zidar N, Jeruc J, Balazic J, Stajer D. Neutrophils in human myocardial infarction with rupture of the free wall. Cardiovasc Pathol. Sep-Oct 2005;14(5):247-50. [Medline].

 
Previous
Next
 
Photograph of the heart of a 43-year-old man demonstrating the site of a stab wound over the left ventricular lateral free wall (shown as a vertical tear).
Photograph of a heart sectioned transversely at the mid left ventricular level showing a posterior ventricular septal defect at the site of a recent acute myocardial infarction.
Photograph of the mitral valve and subvalvular apparatus showing the site of an ischemic papillary muscle (PM) rupture (R).
Magnified photograph of a transverse section of the mid left ventricle (LV) showing a transmural lateral free-wall rupture (R).
Chest radiograph in posteroanterior projection showing a large pseudoaneurysm manifesting as a bulge in the left cardiac border.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.