From the Guidelines
Left ventricular free wall rupture occurs in approximately 0.8-6.2% of patients who experience an acute myocardial infarction (MI). This serious complication typically develops within a short timeframe after an MI and is associated with a high mortality rate due to cardiac tamponade and sudden death. The diagnosis is rarely established before the patient’s death, but in some cases, the presentation of free wall rupture is sub-acute, giving an opportunity for intervention if the condition is recognized 1.
Risk Factors and Clinical Presentation
Risk factors that increase the likelihood of free wall rupture include advanced age, female gender, first-time MI, anterior wall infarction, lack of collateral circulation, and use of certain medications during the acute phase 1. Patients with hypertension during the acute phase of MI are also at increased risk. The clinical presentation of free wall rupture may include signs of cardiogenic shock, sudden hypotension, and/or loss of consciousness, as well as chest pain, nausea, emesis, new ST-segment elevation in the infarct-related leads, or T wave changes.
Diagnosis and Management
Early recognition through echocardiography is essential for diagnosis, and prompt surgical intervention is critical for survival 1. Temporary hemodynamic stabilization can be obtained by pericardiocentesis, fluids, and positive inotropes, but the patient should be immediately transferred to the operating room without any further investigation. The mortality rate for this complication is extremely high, often exceeding 80%, as it frequently leads to cardiac tamponade and sudden death.
Outcome and Quality of Life
Given the high mortality rate associated with left ventricular free wall rupture, prompt recognition and intervention are crucial to improve outcomes and quality of life. The incidence has decreased in recent decades due to improved reperfusion strategies and modern pharmacological treatments for acute MI 1. However, the prognosis remains poor, and early diagnosis and treatment are essential to reduce morbidity and mortality.
From the Research
Incidence of Left Ventricular Free Wall Rupture
- The frequency of left ventricular free wall rupture (LVFWR) in individuals with acute myocardial infarction (AMI) ranges from 1 to 6 percent 2.
- A study published in 2021 reported that LVFWR occurs in 2-4% of patients who suffer from acute MI 3.
- Another study from 2019 found an overall incidence of 0.14% in a cohort of 5143 patients with AMI 4.
- The incidence of LVFWR has decreased compared to the pre-thrombolysis era, where autopsies revealed an incidence of approximately 8% 4.
Clinical Presentation and Diagnosis
- LVFWR may present with subtle symptoms, including unexplained hypotension and transient bradycardia, and ECG features such as persistent ST-segment elevation with T-waves failing to invert in the same leads 2.
- Pericardial effusion of more than 5-10 mm, with echo-dense masses overlying the heart, is highly suggestive of heart rupture on echocardiographic subcostal view 2.
- Rapid diagnosis is essential, but diagnostic tests may be inconclusive, and a high index of suspicion for rupture is necessary 3.
Management and Outcome
- Emergency surgery is indicated for LVFWR, and repair of the ventricular wall is usually achieved by suturing the edges of the tear or closing it with patches of artificial material or biological tissues 5, 6.
- The sutureless technique with Teflon felt and glue may be a promising strategy for treating postinfarction LVFWR 6.
- The mortality rate for LVFWR is high, ranging from 75% to 90%, and 30-day mortality continues to be high despite advances in management 5, 4.