Myocardial rupture
Background
- Rupture includes defects in the atria, ventricles, or junctions of major vessels
Etiology
- MI – “Softening” of myocardium[1]
- 1.7% of patients in reperfusion era
- Typically 24-48h (vs 3-5d in prereperfusion era or without care)
- Trauma – blunt and penetrating trauma
- Penetrating trauma tends to affect RV
- RV 43%, LV 23%, RA 13%, LA 11%, Pericardium alone 10%[2]
- Infection – Endocarditis and myocardial necrosis[3]
- Rare
- Iatrogenic – Pacer wire placement[4]
- Small perforations which rarely lead to tamponade or hemodynamic consequences
Clinical Features
- Chest pain, SOB
- Obvious chest injury
- Hypotension
- JVD
- Muffled heart sounds or new murmur or rub
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
Workup
- Visualization after thoracotomy
- Ultrasound
- Pericardial effusion
- RV diastolic collapse, effusion, there is often RA systolic and diastolic collapse seen also
- Doppler interrogation across the mitral valve will demonstrate exaggerated respiratory variability of transvalvular flow, this is 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
Management
- Pericardiocentesis in cases of tamponade
- Thoracotomy in traumatic cases
- Penetrating chest trauma w/ signs of life in the field
- Blunt chest trauma w/ signs of life lost in ED
- Definite treatment is emergency surgical repair
Disposition
- In the setting of MI, ruptures are near 100% fatal[5]
- Admit via OR with cardiothoracic surgery
See Also
External Links
Sources
- ↑ 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.
- ↑ Beck RC, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists. Thrombolysis. 1999; 33(2):479-487.