Myocardial Rupture Treatment & Management

Updated: Nov 10, 2014
  • Author: Jamshid Shirani, MD; Chief Editor: Eric H Yang, MD  more...
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Treatment

Approach Considerations

Early surgical intervention is essential for the treatment of myocardial rupture; medical therapy plays a supporting role in some instances. Immediate consultation with a cardiothoracic surgeon is indicated in all cases of myocardial rupture. Pericardiocentesis and surgical drainage of hemopericardium may be indicated.

All patients with cardiac rupture should be transferred to the operating room (OR) immediately and admitted to the medical intensive care unit (ICU) or the surgical ICU after operative management. Transfer should be considered only for patients who are in a center without a cardiothoracic surgery unit. The outcome in this setting is quite poor.

Intra-aortic balloon counterpulsation can be used to temporarily stabilize patients with VSD or papillary muscle rupture. Although advocated by some, intra-aortic balloon pumps are not generally used in the treatment of patients with left ventricular (LV) free-wall rupture.

Patients should receive nothing by mouth (nil per os; NPO). Complete bed rest is indicated.

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Pharmacologic Therapy

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 (IV) nitroprusside. In severe cases, insertion of an intra-aortic 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 intra-aortic balloon pump is helpful.

Rapid fluid administration to increase preload and inotropic drugs to improve cardiac output can be useful in cases of free-wall rupture while patients are being transferred to the OR.

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Surgical Repair

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

Papillary muscle rupture is generally treated with mitral valve replacement.

Free-wall rupture is treated by resecting the infarcted area and closing the rupture zone with Teflon or Dacron patches or by using of biologic glues. Successful off-pump surgery (without the use of cardiopulmonary bypass) has been reported.

Ventricular septal defects (VSDs) can be closed directly or by placing 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 that of ventricular rupture.

Coronary artery bypass surgery is often needed as part of the treatment of patients with mechanical complications of AMI undergoing surgical correction (especially patients with VSD). A report from the Society of Thoracic Surgery National Cardiac Database indicated that patients undergoing coronary artery bypass surgery for cardiogenic shock after AMI have a 19% operative mortality; this increases to 31% for those also requiring mitral valve replacement and to 58% for those requiring repair of a ruptured ventricular septum. [9]

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Prevention

Coronary risk factor modification decreases the risk of AMI. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids in the early phase of AMI. Control hypertension and use beta blockers early in patients with AMI. Early successful percutaneous coronary intervention (eg, balloon angioplasty and placement of a stent) reduces the risk of myocardial rupture after AMI.

Using seat belts can significantly reduce the rate of blunt thoracic trauma resulting from high-speed accidents.

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