Myocardial rupture: Difference between revisions
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==Background== | ==Background== | ||
* | *Defects in atria, ventricles, or junctions of major vessels | ||
===Etiology=== | ===Etiology=== | ||
*[[Myocardial infarction]] | *[[Myocardial infarction]] causes “softening” of myocardium<ref>Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.</ref> | ||
**1.7% of MI patients | **Complication seen in 1.7% of MI patients | ||
**Typically | **Typically 24-48h post-MI but can occur up to two weeks post-MI | ||
**Rupture in the setting of MI is nearly 100% fatal<ref>Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.</ref> | **Rupture in the setting of MI is nearly 100% fatal<ref>Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.</ref> | ||
* | *Blunt or penetrating [[cardiac trauma]] | ||
**Penetrating trauma tends to affect RV | **Penetrating trauma tends to affect RV most often <ref>Jin-mou Gao MD, et al. Penetrating cardiac wounds: Principles for surgical management. World Journal of Surgery. 2004; 28(10)1025-1029.</ref> | ||
***RV 43% | |||
***LV 23% | |||
***RA 13% | |||
***LA 11% | |||
**Pericardium only 10% | |||
*Infection | *Infection (rare) | ||
**[[Endocarditis]] and myocardial necrosis<ref>Qizilbash AH and Schwartz CJ. False aneurysm of left ventricle due to perforation of mitral-aortic intervalvular fibrosa with rupture and cardiac tamponade: Rare complication of infective endocarditis. 1973; 32(1) :110-113.</ref> | |||
*Iatrogenic | *Iatrogenic | ||
**Tend to be small perforations | **Pacer wire placement<ref>Trigano JA, et al. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med. 1999; 28:836–40.</ref> | ||
***Tend to be small perforations | |||
***Tamponade and hemodynamic instability are rare | |||
==Clinical Features== | ==Clinical Features== | ||
*Chest pain | *[[Chest pain]] | ||
*[[Shortness of breath]] | |||
*Obvious chest injury | *Obvious chest injury | ||
*Hypotension | *[[Hypotension]] | ||
*JVD | *JVD | ||
*Muffled heart sounds or | *Muffled heart sounds or rub | ||
*New [[murmur]] (heard best at apex, may be confused for mitral regurgitation) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Template:Chest Pain DDX}} | {{Template:Chest Pain DDX}} | ||
== | ==Evaluation== | ||
*[[ | *[[Cardiac ultrasound|Ultrasound]] | ||
**Pericardial effusion | **[[Pericardial effusion]] | ||
**Tamponade physiology (e.g. RV diastolic collapse) | **[[Tamponade]] physiology (e.g. RV diastolic collapse) | ||
**Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow (due to the phenomenon of ventricular interdependence) | **Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow (due to the phenomenon of ventricular interdependence) | ||
*[[ECG]] | *[[ECG]] | ||
**Tachycardia (bradycardia is ominous finding) | **Tachycardia (bradycardia is ominous finding) | ||
**Normal or low voltage | **Normal or low voltage | ||
**Electrical alternans | **Electrical alternans | ||
**Low voltage QRS | |||
*[[CXR]] | *[[CXR]] | ||
**Enlarged cardiac silhouette | **Enlarged cardiac silhouette | ||
*[[Pulsus | *[[Pulsus paradoxus]] | ||
**>10mmHg change in systolic BP on inspiration | **>10mmHg change in systolic BP on inspiration | ||
*Direct visualization on thoracotomy (if indicated) | *Direct visualization on thoracotomy (if indicated) | ||
Latest revision as of 16:01, 15 August 2019
Background
- Defects in atria, ventricles, or junctions of major vessels
Etiology
- Myocardial infarction causes “softening” of myocardium[1]
- Complication seen in 1.7% of MI patients
- Typically 24-48h post-MI but can occur up to two weeks post-MI
- Rupture in the setting of MI is nearly 100% fatal[2]
- Blunt or penetrating cardiac trauma
- Penetrating trauma tends to affect RV most often [3]
- RV 43%
- LV 23%
- RA 13%
- LA 11%
- Pericardium only 10%
- Penetrating trauma tends to affect RV most often [3]
- Infection (rare)
- Endocarditis and myocardial necrosis[4]
- Iatrogenic
- Pacer wire placement[5]
- Tend to be small perforations
- Tamponade and hemodynamic instability are rare
- Pacer wire placement[5]
Clinical Features
- Chest pain
- Shortness of breath
- Obvious chest injury
- Hypotension
- JVD
- Muffled heart sounds or rub
- New murmur (heard best at apex, may be confused for mitral regurgitation)
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Evaluation
- Ultrasound
- Pericardial effusion
- Tamponade physiology (e.g. RV diastolic collapse)
- Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow (due to the phenomenon of ventricular interdependence)
- ECG
- Tachycardia (bradycardia is ominous finding)
- Normal or low voltage
- Electrical alternans
- Low voltage QRS
- CXR
- Enlarged cardiac silhouette
- Pulsus paradoxus
- >10mmHg change in systolic BP on inspiration
- Direct visualization on thoracotomy (if indicated)
Management
- Pericardiocentesis in cases of tamponade
- Thoracotomy in traumatic cases
- Penetrating chest trauma with signs of life in the field
- Blunt chest trauma with signs of life lost in ED
- Definite treatment is emergency surgical repair
Disposition
- Admit (likely directly to OR with cardiothoracic surgery)
See Also
External Links
References
- ↑ Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.
- ↑ Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.
- ↑ Jin-mou Gao MD, et al. Penetrating cardiac wounds: Principles for surgical management. World Journal of Surgery. 2004; 28(10)1025-1029.
- ↑ Qizilbash AH and Schwartz CJ. False aneurysm of left ventricle due to perforation of mitral-aortic intervalvular fibrosa with rupture and cardiac tamponade: Rare complication of infective endocarditis. 1973; 32(1) :110-113.
- ↑ Trigano JA, et al. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med. 1999; 28:836–40.