Ventricular Free Wall Rupture in Acute Myocardial Infarction

Abstract

Despite a progressive reduction in acute myocardial infarction mortality over the years, death related to ventricular free wall rupture has not changed. This is mostly related to the catastrophic presentation and death within minutes in the majority of these patients. Once rupture is suspected, bedside echocardiography should be performed immediately, followed by pericardiocentesis and repair of the rupture site as quickly as possible. Measures to prevent cardiac rupture include the administration of beta-blockers and angiotensin-converting enzyme inhibitors unless contraindications exist, and the avoidance of steroidal and nonsteroidal anti-inflammatory agents such as ibuprofen and indomethacin.

Renin-Angiotensin System and Cardiac Rupture After Myocardial Infarction

“…Rupture can occur as early as the first day after infarction, although it most often occurs later in the first week in the setting of myocardial necrosis and neutrophilic infiltration. 4 A combination of factors, both pathological and physiological, make the infarct region most vulnerable within the first 7 to 10 days. This is when cardiac tissue in the involving infarct region is weakest and most friable.…”

“…6,7 While the initial phases of acute infarction are characterized pathologically by neutrophil infiltration and myocyte necrosis, the healing phase of acute MI, beginning after the first week, is typified by mononuclear cell and fibroblast infiltration and the absence of polymorphonuclear leukocytes. 4 Resorption of necrotic myocytes often precedes scar formation, which occurs over the ensuing weeks, with accumulation of fibrillar collagen into an increasingly organized network. The complete healing process usually takes 5 to 6 weeks and ultimately results in a stable scar absent of cellular infiltration.…”

Myocardial Matrix Remodeling and the Matrix Metalloproteinases: Influence on Cardiac Form and Function

“…In the animal studies utilizing MMP inhibition in the post-MI period, particularly that for the selective MMP inhibitor, MMP inhibition was instituted at 5 days post-MI (8,525). This was predicated upon past clinical observations suggesting that interference with the early wound healing response post-MI was associated with adverse consequences (129,199,397). In the PREMIER study, MMP inhibition was instituted within 24 h of the onset of the MI and, therefore, was in place during the initial wound healing period.…”

Dynamic Changes in Myocardial Matrix and Relevance to Disease

“…Use of these agents has led to ventricular rupture and is essentially avoided as post-MI therapies. 65 The best therapeutic strategy for the treatment of fibrosis is prevention. This implies early risk detection and diagnosis.…”