Myocardial Rupture Treatment & Management

Updated: Dec 29, 2020
  • 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 intensive care unit 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 ventricular septal defect 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 ventricular septal defect, 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 operating room.

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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. A 2020 multicenter retrospective study (2001-2018) that reviewed surgical management of postinfarction left ventricular (LV) free-wall rupture and its early outcomes in 140 patients found a 36.4% operative mortality, with the main cause of death low cardiac output syndrome. [14]  Postoperative myocardial rerupture occurred in 10 patients (7.1%). Independent predictors for early operative mortality were preprocedure LV ejection fraction, cardiac arrest at presentation, female sex, and the need for preprocedure extracorporeal life support (including extracorporeal membrane oxygenation [ECMO]). [14]

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. The operative mortality after surgical repair is high, [15, 16, 17]  particularly in the setting of cardiogenic shock. A 2020 retrospective study (2015-2017) of data from eight patients who underwent delayed surgery following postinfarction ventricular septal rupture with cardiogenic shock found that a combination of preoperative mechanical circulatory support and delayed surgery potentially improved patient outcomes possibly by improving end-organ perfusion. [16]  All the patients received preoperative intra-aortic balloon pump support, and five also received ECMO support. No patient underwent emergency repair; it took a median time of 7.1 days from myocardial infarction onset to surgery and 1.9 days from rupture diagnosis to surgery. Operative mortality was 12.5%, there was a 12.5% complication rate associated with mechanical circulatory support, and survival was 62.5% at 2 years. [16]

In a 2020 systematic review and meta-analysis (1998-2020) that comprised data from 6361 patients from 41 studies who underwent surgical repair for postinfarction ventricular septal rupture, investigators found a 38.2% operative mortality [17]  Factors that raised the likelihood of operative mortality were need for pre-/perioperative intra-aortic balloon pump (IABP) support, right ventricular dysfunction at presentation, posterior defects, and emergency surgery. [17]

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. [18]

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Prevention

Coronary risk factor modification decreases the risk of acute myocardial infarction (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.

A risk score to predict cardiac rupture after ST-elevation MI has been proposed; it uses seven predictors: female sex, advanced age, anterior MI, delayed admission, heart rate, leukocytosis, and anemia. [19]

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

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