In a patient with acute myocardial infarction complicated by ventricular free‑wall rupture with tamponade, should coronary revascularization be performed immediately, and how should antithrombotic therapy be managed?

Revascularization in Myocardial Infarction with Ventricular Free-Wall Rupture

In acute MI complicated by ventricular free-wall rupture with tamponade, immediate surgical repair takes absolute priority over coronary revascularization, but CABG should be performed during the same operation whenever coronary anatomy permits. 1

Immediate Recognition and Stabilization

Suspect free-wall rupture when sudden hemodynamic deterioration occurs with electromechanical dissociation (continuing electrical activity but loss of cardiac output and pulse), recurrent chest pain with ST re-elevation, or signs of cardiac tamponade (jugular venous distension, muffled heart sounds, pulsus paradoxus). 1, 2

• Perform immediate bedside echocardiography to confirm pericardial effusion and identify the rupture site. 1, 3
• Pericardial effusion >10 mm is strongly associated with hemopericardium, and two-thirds of these patients develop tamponade or frank rupture. 1
• The cardiac arrest type accounts for 83.3% of cases, with 90.8% presenting with electromechanical dissociation and 100% in-hospital mortality without intervention. 2
• The unstable type (9% of cases) has a 4.5-hour "golden window" from onset to death—this is your only opportunity for rescue. 2

Do NOT perform pericardiocentesis as definitive therapy—it is contraindicated because it risks intensified bleeding and hemodynamic collapse. 1, 4 Pericardiocentesis may be used only as a temporizing bridge measure in subacute presentations when immediate surgery is unavailable. 1

Hemodynamic Support Strategy

Insert an intra-aortic balloon pump (IABP) immediately upon diagnosis to stabilize the patient during preparation for emergency surgery. 1, 3

• IABP reduces myocardial work, improves diastolic coronary perfusion, and provides critical hemodynamic support as a bridge to the operating room. 1, 3
• Most patients with mechanical complications require IABP placement during preparation for coronary angiography and surgery. 1
• VA-ECMO or percutaneous LVAD may be considered for refractory shock, but VA-ECMO is associated with higher mortality and increased bleeding/vascular complications. 3

Surgical Management Algorithm

Emergency surgery with direct suture or patch repair of the ventricular perforation is the only life-saving intervention. 1

Surgical Priorities:

1. Immediate pericardiotomy and evacuation of hemopericardium to relieve tamponade and restore cardiac output. 5, 6

2. Direct closure of the rupture site using pledgeted sutures or patch repair (woven Dacron or pericardial patch). 1, 5, 6

3. Complete coronary revascularization (CABG) should be performed during the same operation because 80% of patients with free-wall rupture have multivessel coronary artery disease. 1, 3, 5

The European Society of Cardiology and ACC/AHA guidelines explicitly state that CABG should be undertaken at the same time as repair of free-wall rupture. 1

Revascularization Decision-Making

Coronary angiography should be performed only if the patient can be stabilized with IABP and pericardial drainage; otherwise, proceed directly to surgery without angiography. 3, 6

• In the unstable type with 4.5-hour survival window, transfer immediately to the operating room for combined repair and revascularization based on intraoperative assessment. 3, 2
• If coronary anatomy was documented before rupture, proceed directly to combined repair and CABG. 3
• Identification of viable myocardium followed by revascularization leads to improved left ventricular function in survivors. 1

Antithrombotic Management

Discontinue all antithrombotic and anticoagulant therapy immediately upon diagnosis of free-wall rupture with tamponade. 1

• Antithrombotic treatment increases the risk of pericardial bleeding and conversion from contained rupture to frank tamponade. 1
• The incidence of Dressler's syndrome (delayed post-MI pericarditis) is higher in patients with pericardial bleeding after antithrombotic treatment. 1
• Do not resume anticoagulation until surgical hemostasis is confirmed and the patient is hemodynamically stable postoperatively. 3

Timing Considerations and Prognosis

Acute free-wall rupture is usually fatal within minutes and does not respond to standard cardiopulmonary resuscitation—only very rarely is there time to bring the patient to surgery. 1

Subacute rupture (25% of cases) presents with thrombus or adhesions sealing the rupture, providing a critical window for intervention. 1

• The stable type (7.7% of cases) has 83.5% in-hospital survival with appropriate surgical intervention. 2
• Survival after combined repair and revascularization is approximately 39.3% in patients who reach the operating room. 7
• Women and older patients tend to survive intervention less often. 7

Critical Pitfalls to Avoid

Do not delay surgery for complete coronary angiography if the patient is unstable—proceed directly to the operating room and perform intraoperative assessment. 3, 2

Do not rely on pericardiocentesis alone—it provides only temporary relief and does not address the underlying rupture or coronary disease. 1, 4

Do not miss the diagnosis—all patients with cardiogenic shock after MI should have immediate echocardiography to detect subacute rupture or tamponade. 7

Do not continue thrombolytics or anticoagulation—these worsen intrapericardial hemorrhage and convert contained ruptures into fatal tamponade. 1