From the Guidelines
Post-infarction free wall rupture is a life-threatening complication that requires immediate surgical intervention, and surgical revascularization is recommended as part of the treatment protocol 1.
Key Considerations
- Patients should be stabilized with intravenous beta-blockers, such as metoprolol, at a dose of 5-10 mg every 5 minutes, and intravenous nitrates, such as nitroglycerin, at a dose of 10-20 mcg/min, prior to surgery.
- Surgical revascularization, including coronary artery bypass grafting (CABG), should be performed as soon as possible, ideally within 6 hours of rupture, to restore blood flow to the affected area and prevent further cardiac damage 1.
- The goal of surgical revascularization is to improve survival and prevent further cardiac damage, as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 1.
Treatment Protocol
- Emergency CABG is recommended in patients undergoing surgical repair of a postinfarction mechanical complication of MI, such as ventricular septal rupture, mitral valve insufficiency, or free wall rupture 1.
- Prompt pericardial drainage and surgical intervention are necessary to salvage patients with rupture of the free wall, resulting in tamponade 1.
- Acute mitral regurgitation due to rupture of the papillary muscle should be treated by immediate surgery and revascularization 1.
From the Research
Post-Myocardial Infarction Free Wall Rupture Treatment
- The treatment of post-myocardial infarction free wall rupture is a life-threatening condition that requires prompt intervention 2, 3, 4, 5, 6.
- Surgical treatment is considered the standard of care, but the optimal timing and approach remain unclear 2, 5, 6.
- Concomitant coronary artery bypass grafting (CABG) has been debated as a treatment option, with some studies showing no significant impact on early and late mortality 2.
- However, subgroup analysis has shown that concomitant CABG may be associated with lower mortality at long term for certain types of complications, such as papillary muscle rupture 2.
Surgical Approaches
- Off-pump external pericardial patch repair has been proposed as a "bridge to recovery" for high-risk patients with left ventricular free wall rupture 4.
- This approach has shown promising results, with 30-day mortality, 1-year survival, and 2-year survival rates of 57%, 42%, and 42%, respectively 4.
- Other surgical approaches, such as ventricular septal rupture repair, have also been studied, with high early mortality rates reported 5.
Percutaneous Therapies
- Percutaneous approaches, such as pericardial fibrin-glue injection and transcatheter edge-to-edge mitral repair, have been proposed as alternative treatment options for high-risk or inoperable patients 3.
- These therapies have shown promise, but further studies are needed to determine their efficacy and safety 3, 6.
Patient Management
- Early diagnosis and management are crucial to improving outcomes in patients with mechanical complications after acute myocardial infarction 6.
- Hemodynamic stabilization often requires a combination of medical therapy and mechanical circulatory support 6.
- Heart team involvement is required to determine appropriate management strategies for patients with mechanical complications after acute myocardial infarction 6.