Rupture of the Heart Complicating Myocardial Infarction

ELDRED D. MUNDTH

Circulation. 1972;46:427-429
doi: 10.1161/01.CIR.46.3.427
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX
75231
Copyright © 1972 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://circ.ahajournals.org/content/46/3/427.citation

Permissions: Requests for permissions to reproduce figures, tables, or portions of articles

originally published in Circulation can be obtained via RightsLink, a service of the Copyright
Clearance Center, not the Editorial Office. Once the online version of the published article for
which permission is being requested is located, click Request Permissions in the middle column
of the Web page under Services. Further information about this process is available in the
Permissions and Rights Question and Answer document.

Reprints: Information about reprints can be found online at:

http://www.lww.com/reprints

Subscriptions: Information about subscribing to Circulation is online at:

http://circ.ahajournals.org//subscriptions/

Downloaded from http://circ.ahajournals.org/ by guest on February 21, 2014

 Rupture of the Heart
Complicating Myocardial Infarction
RUPTURE of the free wall of the heart has
been reported to be the cause of death
in 4-13% of fatal cases of acute myocardial
infarction.' The incidence of this fatal compli-
cation is second only to cardiogenic shock and
arrhythmias as a cause of death.2 Recent
success with acute revascularization in the
surgical management of cardiogenic shock,
similar success with infarctectomy and direct
repair for rupture of the interventricular
septum, and success with mitral valve replace-
ment for papillary muscle rupture has
prompted consideration of a more aggressive
surgical approach to rupture of the heart.3
Rupture of the free wall of the heart usually
occurs within 2 weeks from the time of onset
of the infarct. London and London' found in
a study of 1000 cases of fatal myocardial
infarction that 50% of ruptures occurred within
3 days and 89% within 14 days. The anterior
wall of the left ventricle is involved more
commonly than the posterior wall.4 Rupture of
the free wall of the heart results in hemoperi-
cardium, abrupt hemodynamic deterioration
due to cardiac tamponade, and usually death
within a very short time following rupture.5
An occasional patient may survive periods of
h-hour to several hours. Any consideration of
surgical intervention obviously would require
prompt recognition of the complication and
immediate surgery.
Clinical features which raise the suspicion
of rupture of the heart include an abrupt
decline of the arterial blood pressure, observa-
tion of paradoxic arterial and venous pressure,
and rapidly increasing venous distention.6
These changes associated with abrupt sinus or
nodal bradycardia strongly suggest rupture of
the heart and cardiac tamponade.7 Van Torsel
Address for reprints: Eldred D. Mundth, M.D.,
Department of Surgery, Harvard Medical School and
the General Surgical Service, Massachusetts ,General
Hospital, Boston, Massachusetts 02114.
Circulation, Volume XLVI, September 1972
Downloaded from http://circ.ahajournals.org/ by guest on February 21, 2014
and Edwards,8 in reviewing 40 cases of
cardiac rupture complicating acute myocardial
infarction, presented evidence suggesting that
the symptomatology in several patients was
consistent with a gradual evolution of cardiac
rupture. Lautsch and Lanks9 demonstrated
organizing thrombus at the site of rupture in
65% of the 43 cases studied and similarly
concluded that this suggested a progressive
rather than abrupt rupture. London and
London' reported repeated and prolonged
chest pain occurring in 55% of patients with
cardiac rupture and only in 10% of fatal cases
of infarction without rupture. This was
interpreted as indicating slow leakage of
blood into the pericardial space prior to
complete rupture and death from cardiac
tamponade. Presumably, if imminent or evolv-
ing rupture of the heart could be recognized
clinically prior to the onset of terminal cardiac
tamponade, surgical correction could be un-
dertaken.
Only four attempts at surgical repair of
cardiac rupture complicating acute myocardial
infarction have been reported, with no long-
term survivors.10 11 All four patients were
moribund at the time of surgical therapy. Two
of the patients survived acutely, one dying of
irreversible brain damage 1 month later and
the other of rerupture 37 days postoperatively.
In all cases the ruptured myocardial tissue was
described as of poor character, and difficulty
was encountered in making sutures hold. Use
of patch material of Dacron, pericardium, or
suture reinforcement with strips of polyvinyl
sponge allowed successful repair in two cases.
Rerupture occurred in three of the four cases
in adjacent areas of the left ventricular wall,
varying in time from several minutes to 37
days following initial repair.
When cardiac rupture is suspected and
associated with cardiac tamponade, pericar-
diocentesis should be performed immediately
427
428
using a relatively large-bore intravenous
catheter. The catheter can be left in the
pericardial space during transport of the
patient to the operating room to prevent
recurrent tamponade. This technic has been
effective in the surgical management of
traumatic wounds of the heart associated with
hemopericardium and has allowed successful
repair of severe stab or missile injuries of the
heart.'2
Although the urgency necessitated by
abrupt cardiac rupture and cardiac tampon-
ade alters the logistics of any attempt at
surgical repair, the concept of surgical repair
is not unlike that of emergency infarctectomy
in the treatment of cardiogenic shock or
rupture of the interventricular septum, com-
plicating acute myocardial infarction.3 Infarct-
ectomy alone has not been effective in the
surgical management of patients with massive
infarction and cardiogenic shock unless it has
been combined with repair of a mechanical
defect such as rupture of the ventricular
septum. To gain any reasonable salvage of
patients in refractory cardiogenic shock with-
out associated mechanical defects, acute re-
vascularization, combined with infarctectomy
in some cases, has resulted in significantly
improved survival.13 To be successful in a
significant number of cases of cardiac rupture
treated surgically, it may be necessary to
combine revascularization with repair of the
rupture. To achieve this effectively would
necessitate coronary angiographic equipment
located in the operating room in order to
obtain "on the table" coronary angiographic
study. It is obvious that the patient with
cardiac rupture and developing tamponade
cannot be safely transported to a catheteriza-
tion laboratory for study prior to surgery and
that this study, if done, would have to be done
in the operating room after surgical control of
the rupture had been accomplished.
Even if successful surgical repair of a
cardiac rupture is achieved, and in some
instances combined with revascularization,
recovery of left ventricular function may not
occur to a sufficient degree to support
circulatory demands. In this situation, the
Downloaded from http://circ.ahajournals.org/ by guest on February 21, 2014
EDITORIALS
institution of mechanical circulatory support
might be beneficial in facilitating recovery.
Previous experience with acute revasculariza-
tion and infarctectomy for the treatment of
the cardiogenic shock patient has demonstrat-
ed the effectiveness of intraaortic balloon
pump assistance in early postoperative man-
agement. Diastolic augmentation with the
intraaortic balloon pump has been shown to
increase the mean arterial pressure with a
reduction in left ventricular work and in peak
left ventricular pressure.14 In addition to the
benefit of reducing the left ventricular work
load, the latter effect would help lessen the
tendency for recurrent rupture of the infarct-
ed myocardium by reducing peak left ventric-
ular pressure.
Although the problems associated with
surgical repair of cardiac rupture complicating
myocardial infarction appear nearly insur-
mountable, a well-organized surgical effort,
based upon experience already gained from
the surgical treatment of other complications
of acute myocardial infarction, could probably
succeed in a significant number of cases.
Successful surgical therapy will require: (1)
early diagnosis before the patient sustains a
cardiac arrest, (2) catheter pericardiocentesis
to prevent fatal cardiac tamponade during
transport of the patient to the operating room,
(3) a surgical staff and cardiopulmonary
support system immediately available at all
times, (4) the capacity for intraoperative
coronary angiographic study, and (5) an
effective mechanical circulatory assistance
system available for early postoperative circu-
latory support.
ELDRED D. MUNDTH
References
1. LONDON RE, LONDON SB: Rupture of the heart:
A critical analysis of 47 consecutive autopsy
cases. Circulation 31: 202, 1965
2. FRIEDBERG CK: General treatment of acute
myocardial infarction. Circulation 39 (suppl
IV): IV-252, 1969
3. BUCKLEY MJ, MUNDTH ED, DAGGETT WM,
DESANcTiS RW, SANDERS CA, AUSTEN WG:
Surgical therapy for early complications of
myocardial infarction. Surgery 70: 814,
1971
Circulation, Volume XLVI, September 1972
EDITORIALS
4. KRUMBHAAR EB, CROWELL C: Spontaneous
rupture of the heart. Amer J Med Sci 170: 828,
1925
5. FRIEDBERG CK: Diseases of the Heart, ed 3.
Philadelphia, W. B. Saunders Co., 1969, p
854
6. BIORCK G, MOGENSEN L, NYQUIST 0, ORINUIS
E, SJ6GREN A: Studies of myocardial rupture
with cardiac tamponade in acute myocardial
infarction: I. Clinical features. Chest 61: 4,
1972
7. MEURs AA, Vos AK, VERHEY JB, GERBRANDY J:
Electrocardiogram during cardiac rupture by
myocardial infarction. Brit Heart J 32: 232,
1970
8. VAN TORSEL RA, EDWARDS JE: Rupture of heart
complicating myocardial infarction: Analysis of
40 cases including nine examples of left
ventricular false aneurysm. Chest 61: 104,
1972
9. LAurscH EV, LANKS KW: Pathogenesis of
cardiac rupture. Arch Path (Chicago) 84:
264, 1967
10. LILLEHEI CW, LANDE AJ, RASSMAN WR,
TANAKA S, BLOCK JH: Surgical management of
myocardial infarction: Some promising con-
Circulation, Volume XLVI, September 1972
Downloaded from http://circ.ahajournals.org/ by guest on February 21, 2014
429
cepts utilizing revascularization, mechanical
circulatory assistance, operative treatment of
severe complications and cardiac replacement.
Circulation 39 (suppl IV): IV-315, 1969
1 1. L6FSTROM B, MOGENSEN L, NYQUIST 0,
ORINuIs E, SJOGREN A, WERNER B: Studies of
myocardial rupture with cardiac tamponade in
acute myocardial infarction: III. Attempts at
emergency surgical treatment. Chest 61: 10,
1972
12. BEALL AC JR, DIETHRICH EB, CRAWFORD HW,
COOLEY DA, DEBAKEY ME: Surgical manage-
ment of penetrating cardiac injuries. Amer J
Surg 112: 686, 1966
13. MUNDTH ED, BUCKLEY MJ, LEINBACH RC,
DESANCTIs RW, SANDERS CA, KANTROWIIZ A,
AUSTEN WG: Myocardial revascularization for
the treatment of cardiogenic shock complicat-
ing acute myocardial infarction. Surgery 70:
78, 1971
14. SANDERS CA, BUCKLEY MJ, LEINBACH RC,
MUNDTH ED, AUSTEN WG: Mechanical circu-
latory assistance: Current status and experience
with combining circulatory assistance, emer-
gency coronary angiography, and acute myo-
cardial revascularization. Circulation 45: 1292,
1972