Proteomic analysis of plasma proteins from patients with cardiac rupture after acute myocardial infarction using TMT-based quantitative proteomics approach

BACKGROUND

Cardiac rupture (CR) is a rare but catastrophic mechanical complication of acute myocardial infarction (AMI) that seriously threatens human health. However, the reliable biomarkers for clinical diagnosis and the underlying signaling pathways insights of CR has yet to be elucidated.

METHODS

In the present study, a quantitative approach with tandem mass tag (TMT) labeling and liquid chromatography-tandem mass spectrometry was used to characterize the differential protein expression profiles of patients with CR. Plasma samples were collected from patients with CR (n = 37), patients with AMI (n = 47), and healthy controls (n = 47). Candidate proteins were selected for validation by multiple reaction monitoring (MRM) and enzyme-linked immunosorbent assay (ELISA).

RESULTS

In total, 1208 proteins were quantified and 958 differentially expressed proteins (DEPs) were identified. The difference in the expression levels of the DEPs was more noticeable between the CR and Con groups than between the AMI and Con groups. Bioinformatics analysis showed most of the DEPs to be involved in numerous crucial biological processes and signaling pathways, such as RNA transport, ribosome, proteasome, and protein processing in the endoplasmic reticulum, as well as necroptosis and leukocyte transendothelial migration, which might play essential roles in the complex pathological processes associated with CR. MRM analysis confirmed the accuracy of the proteomic analysis results. Four proteins i.e., C-reactive protein (CRP), heat shock protein beta-1 (HSPB1), vinculin (VINC) and growth/differentiation factor 15 (GDF15), were further validated via ELISA. By receiver operating characteristic (ROC) analysis, combinations of these four proteins distinguished CR patients from AMI patients with a high area under the curve (AUC) value (0.895, 95% CI, 0.802-0.988, p < 0.001).

CONCLUSIONS

Our study highlights the value of comprehensive proteomic characterization for identifying plasma proteome changes in patients with CR. This pilot study could serve as a valid foundation and initiation point for elucidation of the mechanisms of CR, which might aid in identifying effective diagnostic biomarkers in the future.

Impact of COVID-19 on incidence and outcomes of post-infarction mechanical complications in Europe

OBJECTIVES

Post-acute myocardial infarction mechanical complications (post-AMI MCs) represent rare but life-threatening conditions, including free-wall rupture, ventricular septal rupture and papillary muscle rupture. During the coronavirus disease-19 (COVID-19) pandemic, an overwhelming pressure on healthcare systems led to delayed and potentially suboptimal treatments for time-dependent conditions. As AMI-related hospitalizations decreased, limited information is available whether higher rates of post-AMI MCs and related deaths occurred in this setting. This study was aimed to assess how COVID-19 in Europe has impacted the incidence, treatment and outcome of MCs.

METHODS

The CAUTION-COVID19 study is a multicentre retrospective study collecting 175 patients with post-AMI MCs in 18 centres from 6 European countries, aimed to compare the incidence of such events, related patients' characteristics, and outcomes, between the first year of pandemic and the 2 previous years.

RESULTS

A non-significant increase in MCs was observed [odds ratio (OR) = 1.15, 95% confidence interval (CI) 0.85-1.57; P = 0.364], with stronger growth in ventricular septal rupture diagnoses (OR = 1.43, 95% CI 0.95-2.18; P = 0.090). No significant differences in treatment types and mortality were found between the 2 periods. In-hospital mortality was 50.9% and was higher for conservatively managed cases (90.9%) and lower for surgical patients (44.0%). Patients admitted during COVID-19 more frequently had late-presenting infarction (OR = 2.47, 95% CI 1.24-4.92; P = 0.010), more stable conditions (OR = 2.61, 95% CI 1.27-5.35; P = 0.009) and higher EuroSCORE II (OR = 1.04, 95% CI 1.01-1.06; P = 0.006).

CONCLUSIONS

A non-significant increase in MCs incidence occurred during the first year of COVID-19, characterized by a significantly higher rate of late-presenting infarction, stable conditions and EuroSCORE-II if compared to pre-pandemic data, without affecting treatment and mortality.

Cardiac rupture during the course of treatment for acute purulent pericarditis caused by Staphylococcus aureus: a case report

Background

Purulent pericarditis is rare in the modern era of antibiotics. However, it is a rapidly progressive, life-threatening disease with complications, including cardiac tamponade and left ventricular pseudoaneurysm.

Case summary

A 44-year-old female was admitted with a pontine haemorrhage. On the 25th day of admission, she developed a fever along with chest pain and dyspnoea. Transthoracic echocardiography and computed tomography revealed a large pericardial effusion, leading to the diagnosis of cardiac tamponade. Pericardiocentesis was performed, resulting in the drainage of 750 mL of blood-stained fluid. Blood and pericardial fluid cultures were positive for Staphylococcus aureus; therefore, ceftriaxone was administered. On the 49th day, she became febrile again, and computed tomography showed increased pericardial effusion. Transthoracic echocardiography confirmed the large pericardial effusion and revealed a pseudoaneurysm on the inferior of the left ventricular wall, with blood flowing from the pseudoaneurysm into the pericardial space. Urgent surgical intervention was performed to repair a myocardial defect as a left ventricular pseudoaneurysm had ruptured in the pericardium. The patient recovered and was transferred to another hospital for rehabilitation after 108 days of hospitalization.

Discussion

Purulent pericarditis can be a lethal complication; therefore, careful follow-up and strict adherence to therapeutic strategies, including the use of imaging technologies such as echocardiography, are important.

ALKBH5 induces fibroblast-to-myofibroblast transformation during hypoxia to protect against cardiac rupture after myocardial infarction

INTRODUCTION

N6-methyladenosine (m6A) methylation produces a marked effect on cardiovascular diseases. The m6A demethylase AlkB homolog 5 (ALKBH5), as an m6A "eraser", is responsible for decreased m6A modification. However, its role in cardiac fibroblasts during the post-myocardial infarction (MI) healing process remains elusive.

OBJECTIVES

To investigate the effect of ALKBH5 in cardiac fibroblasts during infarct repair.

METHODS

MI was mimicked by permanent left anterior descending artery ligation in global ALKBH5-knockout, ALKBH5-knockin, and fibroblast-specific ALKBH5-knockout mice to study the function of ALKBH5 during post-MI collagen repair. Methylated RNA immunoprecipitation sequencing was performed to explore potential ALKBH5 targets.

RESULTS

Dramatic alterations in ALKBH5 expression were observed during the early stages post-MI and in hypoxic fibroblasts. Global ALKBH5 knockin reduced infarct size and ameliorated cardiac function after MI. The global and fibroblast-specific ALKBH5-knockout mice both exhibited low survival rates along with poor collagen repair, impaired cardiac function, and cardiac rupture. Both in vivo and in vitro ALKBH5 loss resulted in impaired fibroblast activation and decreased collagen deposition. Additionally, hypoxia, but not TGF-β1 or Ang II, upregulated ALKBH5 expression in myofibroblasts by HIF-1α-dependent transcriptional regulation. Mechanistically, ALKBH5 promoted the stability of ErbB4 mRNA and the degradation of ST14 mRNA via m6A demethylation. Fibroblast-specific ErbB4 overexpression ameliorated the impaired fibroblast-to-myofibroblast transformation and poor post-MI repair due to ALKBH5 knockout.

CONCLUSION

Fibroblast ALKBH5 positively regulates post-MI healing by stabilization of ErbB4 mRNA in an m6A-dependent manner. ALKBH5/ErbB4 might be potential therapeutic targets for post-MI cardiac rupture.

Unveiling a rare case: Cardiac rupture secondary to acute occlusion of the distal left circumflex artery detected by contrast-enhanced spiral CT

A 79-year-old female patient was admitted to the hospital due to intense chest pain. Emergency percutaneous coronary intervention (PCI) revealed an occlusion in the distal portion of the left circumflex artery (LCx). The patient suffered from cardiac rupture, an uncommon yet extremely perilous condition, within 30 minutes following the procedure. This was verified through a computed tomography angiography (CTA) scan and bedside echocardiography. The etiology of cardiac rupture remains elusive, yet potential factors such as the patient's age, gender, initial acute myocardial infarction (AMI), and single-vessel disease without collateral circulation may be linked to this occurrence. This case report emphasizes that occluded tiny distal coronary arteries can also induce cardiac rupture and that a sufficient level of suspicion for the diagnosis of cardiac rupture should be raised when adequate fluid resuscitation fails to alleviate hypotension. Additionally, contrast-enhanced spiral computed tomography (CESCT) is highly effective in revealing certain pathological features associated with cardiac rupture.

Cardiac wall rupture in systemic lupus erythematosus: a case report and review of the literature

Cardiac wall rupture (CWR) is a serious and often fatal complication of myocardial infarction (MI). Despite an increase in the incidence of MI in patients with systemic lupus erythematosus (SLE), cases of CWR in these patients have been reported rarely. This study reports an SLE patient with CWR and pseudoaneurysm formation and reviews previously reported cases of CWR in SLE patients. An English language literature review of from the PubMed, EMBASE, and Scopus databases on published cases of CWR in SLE, up until January 2023, was performed and analyzed. The search identified 4 patients, including the present one, 5 cases altogether. All of them were female aged 27-40 years, and 3 of them had had SLE for 10 years or more. Chest pain and dyspnea were the common presentations. All had left ventricular (LV) wall rupture. Three patients had LV wall rupture with pseudoaneurysm formation (one had MI with normal coronary artery, one myocardial necrosis secondary from small coronary artery vasculitis and one MI from uncertain cause). The other 2 patients had LV free wall rupture (one had MI with extensive coronary atherosclerosis with coronary arteritis, and the other septic myocarditis with septic coronary arteritis) and these 2 patients died before the diagnosis was made. Three patients with pseudoaneurysm received surgical correction with good clinical outcomes in all. Cardiac wall rupture is a serious and often fatal cardiac complication. Emergency diagnosis and appropriate management with an experienced cardiology team is crucial. Surgical correction is the treatment of choice. Key Points • Cardiac wall rupture, a serious and often fatal cardiac complication, has rarely been described in SLE patients. • Emergency diagnosis and appropriate management with an experienced cardiology team is crucial. Surgical correction is the treatment of choice.

Cardiac rupture during acute myocardial infarction : Autopsy study (2004-2020)

INTRODUCTION

Cardiac rupture is a rare but critical complication of myocardial infarction with an incidence of 1 to 3% of cases. We aimed in this autopsy study to analyze the anatomical, epidemiological, cardiac, and coronary profiles of cardiac rupture in the Monastir region.

METHODS

We conducted a descriptive study with retrospective data collection of all cases of myocardial infarction complicated by a cardiac rupture over seventeen years (2004-2020).

RESULTS

Thirty-one cases were included in this study. The mean age of the cases was 67 years with a male predominance. Sixteen cases (57%) had cardiovascular risk factors. The most common symptomatology reported before death was acute chest pain in 57% of cases. Fourteen cases (45%) corresponded to the definition of sudden cardiac death. At autopsy, the heart had a mean weight of 452.78 grams. A large hemopericardium was associated in 90% of cases. Myocardial rupture involved the posterior wall of the left ventricle in 50% of cases. The myocardial rupture occurred at a site of acute myocardial infarction in 86% of cases and on a myocardial scar in 14% of cases. The coronary study showed double or triple vessel atherosclerotic coronary artery disease in 57% of cases with fresh thrombi at the infarct-related coronary in 11% of cases.

CONCLUSIONS

Our analysis found that cardiac rupture mostly involved elderly subjects with underlying cardiovascular risk factors. Our findings sustain that age is a determining prognostic factor after acute coronary syndrome with the need for further education and awareness-raising efforts to speed up access to care for these patients.

Factors associated with in-hospital mortality from free wall rupture after acute myocardial infarction

BACKGROUND

Free wall rupture is a fatal and emergency complication of acute myocardial infarction. The factors associated with in-hospital mortality from free wall rupture remain unclear.

OBJECTIVES

To investigate the factors associated with in-hospital mortality from free wall rupture.

METHODS

We performed a single-center, retrospective study. We enrolled 111 consecutive patients with free wall rupture following acute myocardial infarction who were admitted to Fuwai Hospital from January 2005 to May 2021. The primary endpoint was in-hospital death. Clinical characteristics, laboratory data, and treatment modalities associated with in-hospital mortality were analyzed.

RESULTS

Eighty-seven of the 111 study participants died in hospital. Multivariate Cox regression analysis showed that pericardiocentesis (hazard ratio [HR] 0.296, 95% confidence interval [CI] 0.094-0.929, p = 0.037), pericardial effusion at admission (HR 0.083, 95% CI 0.025-0.269, p<0.001), time interval between acute myocardial infarction and free wall rupture (HR 0.670, 95% CI 0.598-0.753, p<0.001), and previous myocardial infarction (HR 0.046, 95% CI 0.010-0.208, p<0.001) were independently associated with in-hospital mortality.

CONCLUSIONS

Pericardiocentesis, pericardial effusion at admission, the acute myocardial infarction to free wall rupture time, and previous myocardial infarction are associated with a lower rate of in-hospital mortality from free wall rupture after acute myocardial infarction.

Surgical repair of post-infarction ventricular free-wall rupture in the Netherlands: data from a nationwide registry

BACKGROUND

Ventricular free-wall rupture (VFWR) is an infrequent but catastrophic complication of acute myocardial infarction (AMI). Most reports about outcome after surgical treatment are single-center experiences. We examined the early and mid-term outcomes after surgical repair of post-AMI VFWR using the Netherlands Heart Registration (NHR) database.

METHODS

We included data from NHR patients (>18 years old) who underwent surgery for post-AMI VFWR between 2014 and 2019. The primary end-point was in-hospital mortality. Secondary outcomes included postoperative complications and mid-term survival.

RESULTS

The study included 148 patients (54.7% male, mean age 66.5±11.1 years). Critical preoperative status was found in 62.6% of subjects. In-hospital mortality was 31.1% (46 of 148). Multivariable analysis identified female sex [odds ratio (OR), 5.49; 95% confidence interval (CI): 2.24-13.46] and critical preoperative status (OR, 4.06; 95% CI: 1.36-12.13) as independent predictors of in-hospital mortality. The overall median postoperative follow-up was 2.2 (interquartile range, 0.7-3.8) years. Overall survival rates at three and five years were 58.9% and 55.7%, respectively. Among hospital survivors, only 15 (14.7%) patients died during follow-up, with a five-year survival rate of 80.8%.

CONCLUSIONS

In-hospital mortality after surgical repair of post-AMI VFWR is considerable. Female sex and preoperative critical status are independent predictors of early postoperative (in-hospital) death. Logistic EuroSCORE I can reliably predict in-hospital mortality (optimal cut-off >33%). Mid-term follow-up of patients surviving in-hospital course shows excellent results.

Uncommon post-infarction pseudoaneurysms: A case report

BACKGROUND

Mechanical complications are a rare presentation in chronic coronary syndromes, which have significantly decreased in the primary coronary intervention era. Incomplete rupture may occur, resulting in pseudoaneurysms (PANs). Early reperfusion decreases the risk of this complication. Echocardiography is the method of choice for diagnosis.

CASE SUMMARY

A 54-year-old female hypertensive patient, with a history of non-revascularized inferior and anterior ST-segment elevation myocardial infarction (MI) 4 years prior, was admitted to the cardiac unit of the hospital with complaints of abdominal pain and dyspnea lasting 2 mo. The patient was hemodynamically stable, and 12-lead electrocardiogram showed persistent ST elevation and Q wave in the inferior and apical regions. Transthoracic echocardiogram in the two-chamber view showed a narrow neck of a wide PAN in the distal apical left ventricular inferior wall. In addition, the apical four-chamber and subcostal views revealed a second bulky PAN of the apical wall separated from the first by a common organizing thrombus. Cardiac magnetic resonance imaging confirmed the coexistence of more than one PAN. The patient received conservative medical treatment, and surgery was scheduled for outside the country. The patient had worsening multiple organ failure and died 4 wk after presentation.

CONCLUSION

Multifocal PANs rarely occur in chronic MI. Attention should be paid to patients with pain and cardiovascular risk factors.

New risk factors for early- and late-onset cardiac rupture in ST-elevation myocardial infarction patients after primary percutaneous coronary intervention

BACKGROUND

Cardiac rupture (CR) is a catastrophic complication of acute myocardial infarction. Primary percutaneous coronary intervention (pPCI) reduces the incidence of CR. This study aimed to investigate the clinical risk factors and characteristics of CR after pPCI.

METHODS

This was a retrospective, case-control, multicenter study. We enrolled 2444 consecutive patients with ST-elevation myocardial infarction (STEMI) who had undergone pPCI between 2009 and 2015; 33 patients experienced CR (1.35%): 19 were assigned as early CR (≤72 h) and 14 as late CR (>72 h). The 132 controls were randomly selected from the 2411 STEMI patients without CR, by matching institutions at a 1:4 ratio.

RESULTS

Multivariate logistic regression revealed that female sex, acute hyperglycemia, thrombocytopenia (platelets <15 × 10⁴/µL), and incomplete revascularization [post-PCI thrombolysis in myocardial infarction (TIMI) <3] were independent risk factors for CR (p<0.05). Older age, female sex, and emergency surgical repair were strongly associated with in-hospital death, which occurred in 66.7% of CR patients (p<0.05). Univariate logistic regression adjusted for age and sex revealed that low systolic blood pressure, anterior infarction, acute hyperglycemia, Killip class >1, and post-PCI TIMI <3 were significantly associated with early CR, and that Killip class >1 and thrombocytopenia were strongly associated with late CR. Early CR occurred more frequently between 12:00 and 21:00 h, whereas the peak incidence of late CR was bimodal between 6:00-12:00 and 21:00-24:00 h.

CONCLUSIONS

In STEMI patients after pPCI, acute hyperglycemia and thrombocytopenia are new risk factors for early and late CR, respectively. Clinical risk factors and time of occurrence of early and late CR may differ in the PCI era.

Association between acute myocardial infarction-to-cardiac rupture time and in-hospital mortality risk: a retrospective analysis of multicenter registry data from the Cardiovascular Research Consortium-8 Universities (CIRC-8U)

Despite the known association of cardiac rupture with acute myocardial infarction (AMI), it is still unclear whether the clinical characteristics are associated with the risk of in-hospital mortality in patients with AMI complicated by cardiac rupture. The purpose of this study was to investigate the association between the time of cardiac rupture occurrence and the risk of in-hospital mortality after AMI. We conducted a retrospective analysis of multicenter registry data from eight medical universities in Eastern Japan. From 10,278 consecutive patients with AMI, we included 183 patients who had cardiac rupture after AMI, and examined the incidence of in-hospital deaths during a median follow-up of 26 days. Patients were stratified into three groups according to the AMI-to-cardiac rupture time, namely the > 24-h group (n = 111), 24-48-h group (n = 20), and < 48-h group (n = 52). Cox proportional hazards regression analysis was used to estimate the hazard ratio (HR) and the confidence interval (CI) for in-hospital mortality. Around 87 (48%) patients experienced in-hospital death and 126 (67%) underwent a cardiac surgery. Multivariable Cox regression analysis revealed a non-linear association across the three groups for mortality (HR [CI]; < 24 h: 1.0, reference; 24-48 h: 0.73 [0.27-1.86]; > 48 h: 2.25 [1.22-4.15]) after adjustments for age, sex, Killip classification, percutaneous coronary intervention, blood pressure, creatinine, peak creatine kinase myocardial band fraction, left ventricular ejection fraction, and type of rupture. Cardiac surgery was independently associated with a reduction in the HR of mortality (HR [CI]: 0.27 [0.12-0.61]) and attenuated the association between the three AMI-to-cardiac rupture time categories and mortality (statistically non-significant) in the Cox model. These data suggest that the AMI-to-cardiac rupture time contributes significantly to the risk of in-hospital mortality; however, rapid diagnosis and prompt surgical interventions are crucial for improving outcomes in patients with cardiac rupture after AMI.

Phosphodiesterase-5a Knock-out Suppresses Inflammation by Down-Regulating Adhesion Molecules in Cardiac Rupture Following Myocardial Infarction

Cardiac rupture is a fatal complication of acute myocardial infarction (MI), associated with increased inflammation and damaged extracellular matrix. C57BL/6 J wild type (WT) and Pde5a knockout (Pde5a^-/-) mice were selected to establish MI model. The rupture rate of Pde5a^-/- mice was significantly reduced (P < 0.01) within 7 days post MI. The cardiac function of Pde5a^-/- mice was better than WT mice both at day 3 and 7 post MI. Immunohistochemical staining and flow cytometry showed neutrophils and macrophages were decreased in Pde5a^-/- mouse hearts. Inflammatory factors expression such as IL-1β, IL-6, IL-8, Mcp-1, TNF-α significantly decreased in Pde5a^-/- mice post MI. Moreover, western blot showed the inhibition of inflammatory response was accompanied by down-regulation of intercellular adhesion molecule-1(ICAM-1) and vascular cell adhesion molecule-1(VCAM-1) in Pde5a^-/- mice. Knockout of Pde5a reduced inflammatory cells infiltration by down-regulating the expression of ICAM-1 and VCAM-1, and prevented early cardiac rupture after MI. All authors declare that they have no conflicts of interest. This article does not contain any studies with human participants performed by any of the authors. All applicable international, national, and institutional guidelines for the care and use of animals were followed.

Heart Rate Reduction with Ivabradine Prevents Cardiac Rupture after Myocardial Infarction in Mice

PURPOSE

Cardiac rupture is a fatal complication following myocardial infarction (MI). An increase in heart rate (HR) is reportedly an independent risk factor for cardiac rupture during acute MI. However, the role of HR reduction in cardiac rupture after MI remains to be fully elucidated. We aimed to evaluate the therapeutic efficacy of HR reduction with ivabradine (IVA) on post-MI cardiac rupture in mice.

METHODS

We induced MI in mice by ligating the left anterior descending coronary artery. Subsequently, we subcutaneously implanted osmotic pumps filled with IVA solution or vehicle (Veh) in the surviving MI mice at 24 h postoperatively. We biochemically analyzed the myocardium on day 5, additionally observed the mice for 10 days, and analyzed the rates of cardiac rupture and non-cardiac rupture death, and survival after MI.

RESULTS

HR was significantly lower in the IVA-treated mice, whereas blood pressure was comparable between the two groups. Compared to the Veh-treated mice, apoptosis was significantly reduced in the MI border zone in the IVA-treated mice. Although there were no differences in the infarct size of the surviving MI mice between the two groups, HR reduction with IVA significantly reduced cardiac rupture (rupture rate 26 and 8% in the Veh-treated and IVA-treated groups, respectively) and improved survival after MI.

CONCLUSION

Our findings suggest that HR reduction with IVA prevents cardiac rupture after MI. This may be particularly effective in MI patients with a high HR who are either unable to adequately tolerate β-blockers or whose HR remains high despite receiving β-blockers.

Cardiac rupture complicating acute myocardial infarction: the clinical features from an observational study and animal experiment

BACKGROUND

Cardiac rupture (CR) is a fatal complication of ST-elevation myocardial infarction (STEMI) with its incidence markedly declined in the recent decades. However, clinical features of CR patients now and the effect of reperfusion therapy to CR remain unclear. We investigated the clinical features of CR in STEMI patients and the effect of reperfusion therapy to CR in mice.

METHODS

Two studies were conducted. In clinical study, data of 1456 STEMI patients admitted to the First Hospital, Xi'an Jiaotong University during 2015.12. ~ 2018.12. were analyzed. In experimental study, 83 male C57BL/6 mice were operated to induce MI. Of them, 39 mice were permanent MI (group-1), and remaining mice received reperfusion after 1 h ischemia (21 mice, group-2) or 4 h ischemia (23 mice, group-3). All operated mice were monitored up to day-10. Animals were inspected three times daily for the incidence of death and autopsy was done for all mice found died to determine the cause of death.

RESULTS

CR was diagnosed in 40 patients: free-wall rupture in 17, ventricular septal rupture in 20, and combined locations in 3 cases. CR presented in 19 patients at admission and diagnosed in another 21 patients during 1 ~ 14 days post-STEMI, giving an in-hospital incidence of 1.4%. The mortality of CR patients was high during hospitalization accounting for 39% of total in-hospital death. By multivariate logistic regression analysis, older age, peak CK-MB and peak hs-CRP were independent predictors of CR post-STEMI. In mice with non-reperfused MI, 17 animals (43.6%) died of CR that occurred during 3-6 days post-MI. In MI mice received early or delayed reperfusion, all mice survived to the end of experiment except one mouse died of acute heart failure.

CONCLUSION

CR remains as a major cause of in-hospital death in STEMI patients. CR patients are characterized of being elderly, having larger infarct and more server inflammation. Experimentally, reperfusion post-MI prevented CR.

A successful off-pump cardiac repair following blunt cardiac rupture - A case report

A 25-year-old male truck driver presented to Emergency Department following unrestrained heavy motor vehicle crash (MVC), when the high-speed truck collided to a wall. He sustained blunt chest trauma from steering wheel and open fracture of right tibia with compartment syndrome. On primary survey, patient was in shock with patent airway. Focused assessment sonography for trauma (FAST) suggested cardiac tamponade for which ultrasound-guided pericardial catheter was placed. After resuscitation patient was taken to the operation theatre. Clam-shell thoracotomy revealed rents in left atrial appendages which were repaired. Fasciotomy of leg was performed and external fixator was applied for open tibia fracture. The patient developed surgical site infection that was treated with local antibiotic and regular dressings. After two weeks, fasciotomy wound was closed with split-skin grafting. At nine-month follow-up, patient was able to resume his occupation as a heavy motor vehicle driver.

Clinical Manifestation, Timing Course, Precipitating Factors, and Protective Factors of Ventricular Free Wall Rupture Following ST-Segment Elevation Myocardial Infarction

Ventricular free wall rupture (FWR) is a catastrophic complication of that occurs after acute myocardial infarction (AMI), and at present, its clinical characteristics are unclear. We analyzed a total of 6,712 consecutive patients who presented with ST-segment elevation myocardial infarction (STEMI), and 78 patients with FWR after STEMI were enrolled in the study. Patients' demographic data, clinical manifestation, laboratory test results, and angiographic features were then collected and analyzed. FWR occurred in 78 cases (1.16%), and the inhospital mortality of FWR was up to 92.3%. Among the 78 FWR patients, 72 obtained accurate rupture time. FWR typically occurred within the first week after the infarct. Compared to late-phase FWR (more than 48 hours after STEMI) patients, early-phase FWR (during 48 hours after STEMI) patients showed significantly higher random glucose and higher percentage of anterior myocardial infarction. Besides, dual antiplatelet therapy (DAPT), β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) were used less frequently in early-phase FWR patients. Moreover, we first reported the precipitating factors of FWR. Defecating, transporting, acute emotional upset, diets, and invasive treatment turned out to be the main triggers for FWR. Furthermore, we found that patients who survived from FWR were younger, had higher β-blocker coverage in the inhospital treatment, and had a higher frequency of primary PCI. FWR remains an infrequent but devastating complication of STEMI. We have found several factors related to the occurrence and prognosis of FWR. This study provides evidence for a better understanding of FWR.

Heart rupture repair during huge mediastinal mass resection - case report

BACKGROUND

Ventricular rupture is rarely described in the literature outside the context of myocardial infarction, infection or neoplasm. It is associated with a high mortality rate due to late presentation and delayed surgical intervention, which involves sutureless or sutured techniques. Comprehensive literature review failed to identify any case of intra-operative right ventricular heart rupture followed by myocardial repair and a complete recovery after a prolonged intensive care unit (ICU) stay.

CASE PRESENTATION

A 57-year-old previously healthy gentleman presented complaining of a new onset shortness of breath for 2 months. A large mediastinal mass was found on chest imaging and biopsy revealed a thymoma. Patient received a neoadjuvant Cisplatin/Doxorubicin/Cyclophosphamide (CAP) regimen chemotherapy then sternotomy and thymectomy en bloc with anterior pericardium. Post-thymectomy, the patient continued to be hypotensive in recovery despite aggressive fluid resuscitation. He was sent back to theatre, aggressive fluid resuscitation continued, surgical site exploration was done by reopening the sternum, and the bleeding source was identified and controlled, but intraoperative asystole developed. During internal cardiac massage, the right ventricle ruptured with a 3 cm defect which was successfully repaired using a pericardial patch without a bypass machine due to unavailability at our cancer center. The patient remained dependent on mechanical ventilation through tracheostomy for a total of 2 months due to bilateral phrenic nerve paralysis, was discharged from ICU to the surgical floor 66 days after the operation and weaned off ventilator support after 85 days, adequate respiratory and physical rehabilitation followed. Patient is doing very well now with excellent performance, and free of tumor recurrence 30 months after surgery.

CONCLUSION

Right ventricular rupture is rarely described outside the context of myocardial infarction and valvular heart disease. Tumor proximity to the heart and neoadjuvant cardiotoxic chemotherapy are the proposed causes for precipitating the cardiac rupture in our case. Post-surgical patients who receive early physical rehabilitation and respiratory physiotherapy have improved survival and outcome.

Late atrioventricular groove disruption presenting 7 years after mitral valve replacement: a case report

Background

Left ventricular rupture is the most feared complication in mitral valve surgery. Despite its low incidence, mortality rates can reach up to 75%. It usually presents on the operating room with a dissecting haematoma followed by massive bleeding after discontinuing cardiopulmomary bypass. However, cardiac rupture may be contained by adherent pericardium or scar tissue leading to chronic formation of a pseudoaneurysm (PSA).

Case summary

A 44-year-old man came to our institution with acute heart failure triggered by community-acquired pneumonia. He underwent mitral valve replacement with a mechanical prosthesis 7 years before and reported suffering from chronic worsening dyspnoea for 18 months. He underwent chest computed tomography scan and cardiac magnetic resonance imaging (CMRI), which showed two extensive left ventricular (LV) multilobulated PSAs. An operative approach was chosen and a tear was found on the posterior atrioventricular groove (AVG), communicating left ventricle with the PSA, which was closed with bovine pericardium patch. After weaning from cardiopulmonary bypass, he presented a diffuse life-threatening bleeding. The surgeons packed his chest with compresses before closing the sternum and he was operatively revised after 48 h. Post-operative CMRI showed that one of the PSAs remained connected with the LV. Despite of all, 1 year after hospital discharge, he remains asymptomatic without signs of heart failure.

Discussion

This case illustrates PSAs' potential to grow for a long period before causing symptoms, the complexity and risks of chronic AVG disruption surgery and the importance of careful annular manipulation and debridement as preventive measures in mitral valve surgery.

Cardiac rupture with intact pericardium: A report of four cases and short review of the literature

Cardiac rupture with intact pericardium is a dangerous lesion due to high and rapid mortality. Its most common etiologies are blunt chest trauma and myocardial infarction. In forensic practice, this type of rupture can involve a complex relationship between trauma and cardiac disease, so clarifying the main cause of rupture is critical. Herein, we present four cases of cardiac rupture with intact pericardium, which were due to trauma, pathology or both. We propose several diagnostic pointers to analyze this uncommon lesion. Furthermore, the possibility of cardiac rupture induced by cardiopulmonary resuscitation should also be discriminated in such cases.

Treatment strategies for post-infarction left ventricular free-wall rupture

Left ventricular free-wall rupture is one of the most fatal complications after acute myocardial infarction. Surgical treatment of post-infarction left ventricular free-wall rupture has evolved over time. Direct closure of the ventricular wall defect (linear closure) and resection of the infarcted myocardium (infarctectomy), with subsequent closure of the created defect with a prosthetic patch, represented the original techniques. Recently, less aggressive approaches, either with the use of surgical glues or the application of collagen sponge patches on the infarct area to cover the tear and achieve haemostasis, have been proposed. Despite such modifications in the therapeutic strategy and surgical treatment, however, postoperative in-hospital mortality may be as high as 35%. In extremely high-risk or inoperable patients, a non-surgical approach has been reported.

Isolated right atrial rupture from blunt trauma: a case report with systematic review of a lethal injury

Background

Isolated right atrial rupture (IRAR) from blunt chest trauma is rare. There are no physical exam findings and non-invasive testing specific to the condition, which result in diagnostic delays and poor outcomes. We present a case of IRAR along with a systematic review of similar cases in the literature.

Case report

A 23-year-old male presented following a motor vehicle accident (MVA). He was bradycardic and hypotensive during transportation; and required intubation. There were contusions along the right chest wall with clear breath sounds, and no jugular venous distension, muffled heart sounds. Hemodynamic status progressively worsened, ultimately leading to his death. However, no external sources of bleeding or evidence of cardiac tamponade was found.

Methods

A search of PubMed, Ovid, and the Cochrane Library using: (Blunt OR Blunt trauma) AND (Laceration OR Rupture OR Tear) AND (Right Atrium OR Right Atrial). Articles were included if they were original articles describing cases of IRAR.

Results

Forty-five reports comprising seventy-five (n = 75) cases of IRAR.

Conclusion

IRAR most commonly occurs following MVAs as the result of blunt chest trauma. Rupture occurs at four distinct sites and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires a high index of suspicion, as patients’ hemodynamics can rapidly deteriorate. The presentations vary depending on multiple factors including rupture size, pericardial integrity, and concomitant injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding source. A pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are favourable with timely recognition and prompt surgical intervention.

Endogenous muscle atrophy F-box is involved in the development of cardiac rupture after myocardial infarction

Muscle atrophy F-box (MAFbx/atrogin-1), an E3 ubiquitin ligase, is a crucial mediator of skeletal muscle atrophy and cardiac hypertrophy in response to pressure overload and exercise. The role of MAFbx in the regulation of cardiac remodeling after myocardial infarction (MI) remains unclear. Permanent coronary ligation of the left coronary artery was performed on MAFbx knockout (KO) and wild-type (WT) mice and MAFbx expression in the WT mice was shown to be significantly increased in the left ventricles after MI. The mortality rate due to post-MI cardiac rupture was significantly decreased in MAFbx KO mice compared to that in the WT mice. DNA microarray and mRNA expression analyses revealed that the upregulation of genes involved in inflammatory processes and cell motility of leukocytes and neutrophils, including Mmp9, Il1b, Cxcl2, and Nlrp3, was significantly attenuated in MAFbx KO mice 1 day after MI. MAFbx downregulation inhibited nuclear factor-κB (Nfkb) activation after MI. Flow cytometry results demonstrated that the myocardial infiltration of neutrophils was suppressed in MAFbx KO mice 1 day after MI. Nlrp3 and Il1b protein levels were decreased in MAFbx KO mice compared with those in the WT mice. MAFbx downregulation significantly attenuated Tnfa-induced Cxcl2, Il1b, and Nlrp3 expression in cardiomyocytes. We conclude that MAFbx plays an important role in the mediation of excessive inflammation, including neutrophil infiltration, inflammasome formation, and production of proinflammatory cytokines through the activation of Nfkb, promoting cardiac rupture after MI.

Cardiac laceration following non-penetrating chest trauma in dog and cat

Cardiac laceration with non-penetrating chest trauma is reported as a common cause of death in human following rapid deceleration in high-speed vehicular accident. In contrast, in veterinary medicine, traumatic rupture of heart and great-vessel structures appears to be an uncommon cause of death. Here we report three cases of cardiac laceration following non-penetrating chest trauma in a one cat and two dogs. In two of these cases, necropsy revealed a rupture of the heart associated with fractures of the ribs and lung contusion; only one case did not exhibit any external chest injury but revealed pericardial tear associated with hemothorax following rupture of the right auricle of the heart. However, in all three presented cases, the thoracic location of the injuries allowed to conclude that the cause of the cardiac rupture was due to a direct impact of the chest wall with a high speed object and consequent transmission of the kinetic force and compression of the heart between left and right thorax. These case reports underline the importance of a systematic and complete macroscopic evaluation of the heart in all cases of death following non-penetrating chest trauma in dog and cat such as in human. They also highlight how, in clinical and forensic practice, the cardiac injury following blunt chest trauma should be ruled out even in the cases of absence of external chest injury.

Ultrasound diagnosis of cardiac rupture caused by mechanical chest compression

A 74-year-old male with chronic kidney disease presented to the emergency department with asystole. Mechanical chest compression was started immediately using a piston-type thumper device. The initial potassium level was 7.7 mEq/L and bedside point-of-care ultrasound (POCUS) revealed no pericardial fluid. With standard resuscitation and anti-hyperkalemia treatment, return of spontaneous circulation (ROSC) was achieved within 10 minutes of compressions. At 15 minutes post-ROSC, the patient went into pulseless electrical activity. A repeated POCUS discovered massive pericardial fluid suggesting the presence of cardiac tamponade. Bedside pericardiotomy was performed followed by open thoracotomy. Laceration of the right ventricular wall adjacent to the fracture site of sternum was found, implicating that it was the complication of mechanical chest compression. After surgical repair and intensive post-operative care, the patient survived with full conscious recovery at day 6 of admission. Our case emphasizes the importance of POCUS in resuscitation, especially when the patient's condition deteriorates unexpectedly.

Splenic Ly6Chi monocytes contribute to adverse late post-ischemic left ventricular remodeling in heme oxygenase-1 deficient mice

Heme oxygenase-1 (Hmox1) is a stress-inducible protein crucial in heme catabolism. The end products of its enzymatic activity possess anti-oxidative, anti-apoptotic and anti-inflammatory properties. Cardioprotective effects of Hmox1 were demonstrated in experimental models of myocardial infarction (MI). Nevertheless, its importance in timely resolution of post-ischemic inflammation remains incompletely understood. The aim of this study was to determine the role of Hmox1 in the monocyte/macrophage-mediated cardiac remodeling in a mouse model of MI. Hmox1 knockout (Hmox1^-/-) and wild-type (WT, Hmox1^+/+) mice were subjected to a permanent ligation of the left anterior descending coronary artery. Significantly lower incidence of left ventricle (LV) free wall rupture was noted between 3rd and 5th day after MI in Hmox1^-/- mice resulting in their better overall survival. Then, starting from 7th until 21st day post-MI a more potent deterioration of LV function was observed in Hmox1^-/- than in the surviving Hmox1^+/+ mice. This was accompanied by higher numbers of Ly6C^hi monocytes in peripheral blood, as well as higher expression of monocyte chemoattractant protein-1 and adhesion molecules in the hearts of MI-operated Hmox1^-/- mice. Consequently, a greater post-MI monocyte-derived myocardial macrophage infiltration was noted in Hmox1-deficient individuals. Splenectomy decreased the numbers of circulating inflammatory Ly6C^hi monocytes in blood, reduced the numbers of proinflammatory cardiac macrophages and significantly improved the post-MI LV function in Hmox1^-/- mice. In conclusion, Hmox1 deficiency has divergent consequences in MI. On the one hand, it improves early post-MI survival by decreasing the occurrence of cardiac rupture. Afterwards, however, the hearts of Hmox1-deficient mice undergo adverse late LV remodeling due to overactive and prolonged post-ischemic inflammatory response. We identified spleen as an important source of these cardiovascular complications in Hmox1^-/- mice.

Development and validation of clinical risk score to predict the cardiac rupture in patients with STEMI

BACKGROUND

Cardiac rupture (CR) is a fatal complication of ST-elevation myocardial infarction (STEMI) with poor prognosis. The aim of this study was to develop and validate practical risk score to predict the CR after STEMI.

METHODS

A total of 11,234 STEMI patients from 7 centers in China were enrolled in our study, we firstly developed a simplified fast-track CR risk model from 7455 STEMI patients, and then prospectively validated the CR risk model using receiver-operating characteristic (ROC) curves by the other 3779 consecutive STEMI patients. This trial is registered with ClinicalTrials.gov, number NCT02484326.

RESULTS

The incidence of CR was 2.12% (238/11,234), and the thirty-day mortality in CR patients was 86%. We developed a risk model which had 7 independent baseline clinical predictors (female sex, advanced age, anterior myocardial infarction, delayed admission, heart rate, elevated white blood cell count and anemia). The CR risk score system differentiated STEMI patients with incidence of CR ranging from 0.2% to 13%. The risk score system demonstrated good predictive value with area under the ROC of 0.78 (95% CI 0.73-0.84) in validation cohort. Primary percutaneous coronary intervention decreased the incidence of CR in high risk group (3.9% vs. 6.2%, p<0.05) and very high risk group (8.0% vs. 15.2%, p<0.05).

CONCLUSIONS

A simple risk score system based on 7 baseline clinical variables could identify patients with high risk of CR, for whom appropriate treatment strategies can be implemented.

Haploinsufficiency of Hand1 improves mice survival after acute myocardial infarction through preventing cardiac rupture

Previous studies have demonstrated a significantly lower level of Hand1 in ischemic cardiomyopathy than in normal heart tissue. The role of decreased Hand1 in myocardial infarction remains unclear. This study was designed to investigate the effects of haploinsufficiency of Hand1 on mouse heart after myocardial infarction. 8-10 weeks old male heterozygous Hand1-deficient (Hand1(+/-)) mice and wild-type littermates (control) were subjected to sham operation or ligation of the left anterior descending coronary artery to induce acute myocardial infarction (AMI). Hand1(+/-) mice have low incidence of left ventricular free wall rupture in the first week after operation than control mice. Then we found lower MMP9 activity and less cardiomyocytes apoptosis in Hand1(+/-) than in control mice. All of these contribute to the protection role of haploinsufficiency of Hand1 after AMI.

Right ventricular free wall dissection as a rupture tract in left ventricular rupture during acute myocardial infarction

Three rare cases of cardiac rupture with right ventricular wall dissection during acute myocardial infarction (AMI) were reported. The cases comprised 2% among our 148 previously reported postinfarction cardiac ruptures with sudden death. The dissections occurred in hearts with biventricular inferior wall AMI and developed between the superficial layers and the deeper layers of inferior wall of the right ventricle. All had an endocardial tear at the basal septum where it meets the inferior free wall of the left ventricle, and had an epicardial tear on the middle inferior wall of the right ventricle. Based on the evidence of the ages of the thrombi of the rupture tracts, delayed epicardial rupture was found besides that soon after the right ventricular dissection.

Predictive factors of cardiac rupture in patients with ST-elevation myocardial infarction

Cardiac rupture (CR) is a potentially fatal mechanical complication of ST-elevation myocardial infarction (STEMI). We aimed to determine the incidence and risk factors of CR in Chinese STEMI patients. A total of 9798 consecutive STEMI patients from four centers in China were retrospectively analyzed, among which 178 patients had CR. STEMI patients without CR were chosen as a control group. Clinical characteristics were compared between STEMI patients with CR and those without CR. The incidence of CR in STEMI patients was 1.82%, and the 30-d mortality was up to 61.2%. CR patients were significantly older, more female, and associated with a longer time from onset of pain to hospital admission than their non-CR counterparts (P<0.001). More patients with anterior myocardial infarction (82.1%) were found in the CR group, and CR patients had significantly higher heart rates than the control group ((91±19) bpm vs. (71±16) bpm; P<0.001). In multiple-adjusted models, the independent risk factors of CR were advanced age, female gender, anaemia, increased heart rate, anterior myocardial infarction, increased white blood cell (WBC) count, delayed admission, and renal dysfunction. The level of hemoglobin remained a significant determinant factor of CR (OR (95% CI): 0.82 (0.75-0.89); P<0.001) after adjusting for various potential confounding factors. Counts of WBC also remained a significant determinant of the CR (OR (95% CI): 1.08 (1.04-1.12); P<0.001). A number of variables were independently related to CR. This study indicated, for the first time, that both hemoglobin and WBC levels were independently correlated with occurrence of CR.

An unusual echocardiographic presentation of left atrial dissection following cardiopulmonary cerebral resuscitation

Left atrial dissection (LatD) is a relatively rare perioperative complication during mitral valve repair. Here, we report a 64-year-old man who developed LatD after cardiopulmonary resuscitation was needed due to an extensive myocardial infarction. Aggressive cardiac massage resulted in cardiac rupture and massive bloody pleura effusion. Intraoperative three-dimensional transesophageal echocardiography revealed posterior-medial papillary muscle ruptured and separation of the endocardium from the left atrial myocardium. We speculate that this is the first report in the literature of LatD after cardiopulmonary cerebral resuscitation.

Metastatic breast cancer with right ventricular erosion

Cancer that has metastasized to the heart and pericardium has a dismal outcome. Individualized treatment to preserve the quality of life and reduce surgical mortality is important. We describe a 57-year old woman who had a recurrence of breast cancer 23 years after the initial complete treatment. Cardiac metastasis with poor anterior chest wall healing led to right ventricular rupture, which caused hypovolaemic shock. The right ventricular wall defect was repaired with a percutaneous patch and a myocutaneous flap without cardiopulmonary bypass. The patient was discharged home after intensive wound care. Our patient shows that even with complete initial treatment, clinicians should be alert for the recurrence of breast cancer.

Attenuation of ER stress prevents post-infarction-induced cardiac rupture and remodeling by modulating both cardiac apoptosis and fibrosis

Endoplasmic reticulum (ER) stress is implicated in the pathophysiology of various cardiovascular diseases, but the role of ER stress in cardiac rupture and/or remodeling after myocardial infarction (MI) is still unclear. Here we investigated whether ER stress plays a major role for these processes in mice. We ligated the left coronary artery (LCA) without reperfusion in mice and administered either NaCl or 4-phenylbutyric acid (4-PBA, 20 mg/kg/d) intraperitoneally for 4 weeks. Cardiac rupture rates during the first week of MI were 37.5% and 18.2% in the control and 4-PBA groups, respectively. The extent of ventricular aneurysm and fibrosis was less, and the cardiac function better, in the 4-PBA group compared with the control group. The protein levels of ER stress markers in the heart tissues of the control group remained elevated during the entire 4-week period after MI, while pro-apoptotic proteins mainly increased in the early phase, and the pro-fibrotic proteins markedly increased in the late phase post MI; 4-PBA decreased all of these protein levels. In the primary cultured neonatal rat cardiomyocytes or fibroblasts, hypoxia (3% O2) increased the number of apoptotic cardiomyocytes and promoted the proliferation and migration of fibroblasts, all of which were attenuated by 4-PBA (0.5 mM). These findings indicate that MI induces ER stress and provokes cardiac apoptosis and fibrosis, culminating in cardiac rupture and remodeling, and that the attenuation of ER stress could be an effective therapeutic target to prevent post-MI complications.

Right massive haemothorax as the presentation of blunt cardiac rupture: the pitfall of coexisting pericardial laceration

A 74-year old female was transferred to our institution because of blunt chest trauma. Chest X-ray and computed tomography (CT) revealed right haemothorax and little pericardial effusion. She was taken to the operating theatre for emergent operation because of hypotension and massive bleeding from the right-sided chest tube. Cardiopulmonary resuscitation was started during surgical exploration. There were three 1-cm lacerations actively bleeding from the right atrium and inferior vena cava junction, which were repaired successfully. Furthermore, we identified a 10 cm laceration in the right-side pleuropericardium and a communication existing between the pericardial space and the right pleural space.

Rupture of the left atrial roof due to blunt trauma

Cardiac rupture after blunt trauma is rare and associated with high mortality. The anatomic pattern of blunt cardiac rupture has been demonstrated with the right cardiac chambers more frequently affected than the left. Furthermore, left atrial injury is usually restricted to the atrial appendage and the pulmonary vein-atrial junction. Herein, we report the first case of a 61-year old man with a rupture of the left atrial roof after blunt trauma with minimal thoracic injury.

Application of percutaneous cardiopulmonary support for cardiac tamponade following blunt chest trauma: two case reports

Since the advent of percutaneous cardiopulmonary support (PCPS), its application has been extended to massively injured patient. Cardiac injury following blunt chest trauma brings out high mortality and morbidity. In our cases, patients had high injury severity score by blunt trauma and presented sudden hemodynamic collapse in emergency room. We quickly detected cardiac tamponade by focused assessment with sonography for trauma and implemented PCPS. As PCPS established, their vital sign restored and then, they were transferred to the operation room (OR) securely. After all injured lesion repaired, PCPS weaned successfully in OR. They were discharged without complication on day 26 and 55, retrospectively.

Challenges in the diagnosis of blunt cardiac injuries

INTRODUCTION

Blunt thoracic injuries (BTIs) are directly responsible for 20-25% of all deaths, worldwide. Involvement of heart in BTIs is largely underestimated and ignored, but reasonable estimate would be around 15%. This study was planned to emphasize on clinical-presentation and diagnosis of blunt cardiac injuries (BCIs).

RESULTS

Clinical presentation of BCIs, varied from mild chest discomfort to haemodynamic shock secondary to rapid exsanguinations. Non-specific presentation with associated injuries diverts physician's attention and delayed appearance of clinical features makes diagnosis further difficult. Cardiac markers and ECG are not specific, but high sensitivity of 100% could be reached using combination of elevated cardiactroponin levels and alterations in ECG. Transoesophageal or transthoracic echocardiography, angiography, intravascular ultrasound and nuclear scan have proven to detect cardiac injuries in BTIs, but lack specificity.

CONCLUSION

Patients with suspicious-ECG finding need cardiac-monitoring for at least 24 hours. Haemodynamically stable young (<55 years) subjects, without underlying cardiac diseases and with normal-ECG and cardiac marker, could be discharged safely.