Early diagnosis of subacute free wall rupture complicating acute myocardial infarction

Abstract

Of 2608 consecutive patients with acute myocardial infarction, 24 developed subacute free wall rupture (= 0.92%; 95% C.I. = 0.6-1.4). Clinical manifestations varied widely (shock on admission; 25% of cases; severe arrhythmias followed by shock: 17%; shock during hospital stay: 42%; symptoms suggestive of infarct extension without shock: 17%). The electrocardiograms were confusing rather than revealing: 56% of patients showed new ST segment elevations of 0.2 to 1 mV in the infarct-related leads, while autopsy or creatinine phosphokinase evidence of infarct extension was missing. In the first 21 cases, therefore, no definitive diagnosis was made before autopsy. Using 197 infarct patients in cardiogenic shock or with infarct extension during the acute stage, i.e. a patient group with comparable clinical manifestations, as control group, a logistic regression model was generated in which the variables age, lateral wall involvement and history of hypertension were used for estimating the probability of subacute rupture. In fact, probability may rise to more than 40% in major subgroups. As death occurred after a median interval of 8 h (45 min-6.5 weeks) following the onset of rupture symptoms, echocardiography must be performed urgently in all cases presenting symptoms of shock or infarct extension. Pretest probability which can be roughly estimated from our model as well as sensitivity and specificity of individual echocardiographic or clinical parameters are indispensable for correct therapeutic decisions. The routine application of this algorithm in our department contributed to a timely diagnosis in the last three consecutive cases of whom one patient survived.

“Swiss-Cheese” Left Ventricle in Acute Myocardial Infarction—A Case Report

“…In the setting of acute myocardial infarction, ST elevation in inferior and anterior leads as shown in Figure 7 as a result of occlusion of a large wraparound left anterior descending coronary artery (Left anterior descending coronary artery (LAD) reaching the apex, wraps around the left ventricular apex and travels some distance in the posterior inter-ventricular groove and supplying the apical inferior aspect of the heart-type III LAD) is associated with an increased risk of ventricular septal rupture [37]. New ST segment changes ("saddle-shaped ST-segment elevation") or persistent non-inversion of T-waves in the affected leads may suggest a less noisy 'stuttering" type of rupture [38]. Postinfarction septal defects are localized in the muscular part of the septum and are associated with a high incidence of left ventricular aneurysm as shown in Figures 9-11 [39] as 30% according to Schlesinger et al [40] and 68% by Hill et al [41].…”

Combination of several rare complications of myocardial infarction in a single patient

“…There are several terms for ruptures that do not traverse all layers of myocardium-slow or incomplete tear leading to a late rupture, or subacute rupture. [16,17] Frequency of VSR and incomplete free wall rupture combined is unknown, but is undoubtedly very low. In our case, the patient's presentation with cardiogenic shock and timely performance of an echocardiogram allowed for rapid diagnosis of these rare complications.…”

Diretrizes

“…O ponto da ruptura em geral não é localizado, pois ocorre por mecanismo de divulsão do miocárdio, e habitualmente não produz orifícios de tamanho suficiente para ser diagnosticados pela ecocardiografia. Devese lembrar que a presença de líquido pericárdico, sem sinais de tamponamento cardíaco, não faz o diagnóstico de ruptura de parede livre, visto que em infartos transmurais comumente se observa derrame pericárdico 120,121 .…”