Cardiac free wall rupture after acute myocardial infarction. Clinical and pathological analysis

Post myocardial infarction cardiogenic shock: a review of current therapies

Cardiogenic shock is often a devastating consequence of acute myocardial infarction (MI) and portends to significant mortality and morbidity. Despite improvements in expediting the time to treatment and enhancements in available medical therapy and reperfusion techniques, cardiogenic shock remains the most common cause of mortality following MI. Post-MI cardiogenic shock most commonly occurs as a consequence of severe left ventricular dysfunction. Right ventricular (RV) MI must also be considered. Mechanical complications including acute mitral regurgitation, ventricular septal rupture, and ventricular free-wall rupture can also lead to cardiogenic shock. Rapid diagnosis of cardiogenic shock and its underlying cause is pivotal to delivering definitive therapy. Intravenous vasoactive agents and mechanical support devices may temporize the patient's hemodynamic status until definitive therapy by percutaneous or surgical intervention can be performed. Despite prompt management, post-MI cardiogenic shock mortality remains high.

Emergency department two-dimensional echocardiography in the diagnosis of nontraumatic cardiac rupture

Myocardial rupture is a catastrophic complication of acute myocardial infarction that usually results in sudden death. If diagnosed quickly, patients with myocardial rupture may be salvaged. This report describes the application of emergency department two-dimensional echocardiography in the diagnosis of six cases of myocardial rupture over two years. Each demonstrated a characteristic hemopericardium on limited single-window examination. These included four patients who met institutional guidelines for thrombolytic therapy. Three patients survived surgical repair, with two long-term survivors.

Postinfarction rupture of the left ventricular free wall: clinicopathologic correlates in 100 consecutive autopsy cases

Among 100 consecutive autopsied cases of postinfarction rupture of the left ventricular free wall, 51% of the deaths were in-hospital and 49% were out of hospital. There were 51 men (mean age, 72 years) and 49 women (mean age, 76 years); 81% had multivessel disease. All had severe obstruction of at least one major epicardial coronary artery (98 atherosclerotic, one thrombotic, and one embolic). Acute coronary thrombosis was present in 73 cases and occurred on an atherosclerotic plaque in 72, 49 (68%) of which had associated plaque rupture. In 83 cases, the ruptured infarction represented the subject's first myocardial infarction. Despite a history of hypertension in 55 cases, appreciable left ventricular hypertrophy was observed in only 19 cases. By histopathologic age of infarction, 13 ruptures occurred during the first day, 45 between days 2 and 5, and 22 on days 6 and 7; thus, 58% occurred within 5 days and 80% within 7 days. The mid-ventricle was the most frequent site of rupture (66%). Ruptures most frequently involved the lateral aspect of the left ventricular free wall (44%). In 66 cases, the rupture tract occurred along the interface between viable and necrotic myocardium. Our findings support the observations of others that the risk factors for postinfarction left ventricular free wall rupture include age greater than 60 years, female gender, preexisting hypertension, absence of left ventricular hypertrophy, first myocardial infarction, and midventricular or lateral wall transmural infarctions.

Classification of cardiac rupture complicated in myocardial infarction. Pathological study of 32 cases

Thirty of 32 cases with cardiac rupture (CR) complications in the myocardial infarction were found out of a total of 91 cases of acute myocardial infarction (AMI). The mean age of the ruptured group in females was significantly younger than that of the non-ruptured group. Twenty-one cases showed free wall rupture of the left ventricle, six perforation of ventricular septum and three double rupture. All cardiac ruptures occurred in cases of transmural infarction. The age of AMI was histologically estimated. Nine cases complicated within the first 24 hours of AMI showed rupture of the left anterior wall. CR in the periphery within the infarct occurred at any time during the first week after onset, and cases of the central rupture were increased in number after the 3rd day of AMI. Pathologic findings indicated that elevated wall tension was considered to be most closely related to the cause of CR. Thirty two cases of CR were classified into three types: (1) blowout type, (2) hemorrhagic dissecting type, and (3) thinning-with-rupture type. Hemorrhagic dissecting type was characterized by multiple endocardial ulcers and fissure canals extending from the ulcer with hemorrhage in the surrounding myocardium. Complex fissure was seen in two cases of this type.