From the Guidelines
Clinical Manifestations of Post-Myocardial Infarction Free Wall Rupture
Post-myocardial infarction (MI) free wall rupture is a life-threatening complication that requires immediate medical attention. The clinical manifestations of this condition can vary but often include sudden death due to cardiac tamponade and electromechanical dissociation 1. In some cases, the presentation can be sub-acute, with signs of cardiogenic shock, sudden hypotension, and/or loss of consciousness 1.
Key Clinical Features
- Chest pain: Recurrent chest pain and ST-T-wave changes are common presentations of free-wall rupture 1.
- Hemodynamic instability: Rapid progression to hemodynamic collapse, electromechanical dissociation, and death can occur 1.
- Pericardial effusion: The presence of pericardial fluid with or without signs of tamponade can be detected by echocardiography 1.
- Echodense mass: An echodense mass in the pericardial space consistent with clot (haemopericardium) is a typical finding 1.
Risk Factors
- First MI: Free-wall rupture is observed most frequently in patients with first MI 1.
- Anterior infarction: Anterior infarction is a risk factor for free-wall rupture 1.
- Elderly and women: The elderly and women are at higher risk of free-wall rupture 1.
Management
Management involves aggressive hemodynamic support with vasopressors and inotropes, pericardiocentesis to relieve tamponade, and surgical repair to prevent further rupture, typically within 24 hours of diagnosis 1. Immediate surgery should be considered depending on the clinical status 1.
Diagnostic Approach
- Echocardiography: Should always be performed in acute heart failure to assess LV function and to rule out life-threatening mechanical complications 1.
- Transthoracic echocardiography: Can recognize pseudoaneurysm formation with contained rupture and tamponade 1.
From the Research
Clinical Manifestations of Post-Myocardial Infarction Free Wall Rupture
The clinical manifestations of post-myocardial infarction (MI) free wall rupture include:
- Recurrent chest pain, which can lead to death within minutes of onset 2
- Cardiac tamponade secondary to free wall rupture of the left ventricle (LV) in the presence of acute myocardial infarction 3
- Ventricular pseudoaneurysm, papillary muscle rupture, and ventricular septal rupture, which are life-threatening mechanical complications of acute myocardial infarction 4
- Hemodynamic instability, which requires aggressive management with invasive monitoring, inotropes, vasodilators, and an intra-aortic balloon pump 5
Diagnosis and Management
Diagnosis and management of post-MI free wall rupture involve:
- Prompt evaluation and diagnosis to improve survival 6
- Surgical repair, which is the treatment of choice 2
- Percutaneous approaches, such as pericardial fibrin-glue injection, which can be used as therapeutic alternatives to open surgery in selected high-risk or inoperable patients 4
- Off-pump external pericardial patch repair, which can be used as a 'bridge to recovery' in high-risk patients 3
- Urgent catheterization and diagnosis of in-stent thrombosis, which can lead to transmural necrosis and free wall rupture 2