Survival after subacute cardiac rupture.

Abstract

SUMMARY A 43-year-old man collapsed suddenly, with pericardial tamponade, seven weeks after an inferior myocardial infarction. Pericardiocentesis disclosed very heavily blood stained fluid. Left ventricular angiography 10 days later showed a left ventricular aneurysm. At operation a left ventricular false aneurysm was resected and the patient recovered uneventfully.Cardiac rupture occurs in 4 to 24% of all deaths from acute myocardial infarction.' It may occur from a few hours to several days after the infarction and is usually fatal. It is not usually an acute "blowout", but a gradual penetration of the necrotic myocardium by a dissecting haematoma,I leading to cardiac tamponade. Surgical treatment of this complication has occasionally been successful. We report a case of cardiac rupture that occurred seven weeks after myocardial infarction and was subsequently treated surgically. Case reportA 43-year-old mechanic was admitted to hospital with a two day history of praecordial pain radiating down both arms and up to the throat. The pain was intermittent but had gradually increased in intensity. There was no significant past medical history.On physical examination his general condition appeared good. His pulse rate was 80 per minute, regular, and his blood pressure was 160/110 mnmHg. There was no evidence of cardiac failure. The electrocardiogram confirmed an acute inferior myocardial infarction. The chest x-ray film showed slight cardiomegaly. From 180Two weeks later, he had a sudden onset of dizziness followed by two transient syncopal episodes. This was soon followed by upper chest pain which radiated to the throat and was aggravated by deep inspiration and lying flat. On examination he was pale, cold, clammy, and dyspnoeic. Pulse was 120 per minute, regular, and of low volume. The systolic blood pressure by palpation was 70 mmHg on expiration, falling to 50 mmHg on inspiration. The jugular venous pressure was raised 8 cm above the sternal angle. The heart sounds were inaudible. The electrocardiogram showed the presence of the previous inferior myocardial infarction. An anteroposterior portable chest x-ray film showed probable cardiomegaly. An echocardiogram showed a large echo-free space anteriorly and posteriorly, indicating a pericardial effusion.A diagnosis of pericardial tamponade was made and pericardiocentesis was carried out using the apical approach. On removal of 67 ml heavily bloodstained fluid, there was a dramatic clinical improvement and the blood pressure rose to 110/70 mmHg. The pericardial fluid haemoglobin was 10-4 g/dl and the circulating blood haemoglobin was 14-4 g/dl; the erythrocyte sedimentation rate was 22 mm/hour. He was transferred by ambulance to the Middlesex Hospital Cardiothoracic Surgical Unit, with a pericardial drain in situ but closed off. His general condition continued to improve so operation was deferred.Left ventricular angiography, 10 days after his collapse, showed a large saccular posteroinferior left ventricular aneurysm (Fig.). This showed paradoxical movement and...