Ventricular free wall rupture following acute myocardial infarction

Abstract

Ventricular free wall rupture remains a dreaded complication of acute myocardial infarction. A dramatic fatal presentation is not universal and if recognized early, especially in its sub-acute form, a therapeutic intervention may be lifesaving. Changing trends in its natural history and the previously described pathological subtypes have emerged since the advent of thrombolysis. Although frequently unpredictable, certain clinical, echocardiographic and electrocardiographic signs should suggest the diagnosis. Moreover, knowledge of predisposing risk factors and a high index of suspicion are helpful in early recognition of this complication. In recent years, several different therapeutic approaches have been described including percutaneous seals and surgical mechanical closure of ventricular free wall rupture. In this review, we sought to highlight established and debatable aspects of this pathology to hopefully enhance prompt diagnosis and treatment by all clinicians caring for patients suffering acute myocardial infarction.

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

“…484 It is observed most frequently in patients with first MI, anterior infarction, the elderly, and women. Other risk factors include hypertension during the acute phase of STEMI, lack of antecedent angina or prior MI, absence of collateral blood flow, Q waves on ECG, use of corticosteroids or nonsteroidal anti-inflammatory drugs, and administration of fibrinolytic therapy >14 hours after symptom onset.…”

Acute Myocardial Infarction in Women

“…216 Left ventricular free wall rupture and tamponade are more common in women after AMI. [382][383][384] Older age, anterior AMI, and delayed thrombolysis are additional risk factors. 374,382,383,385 Primary PCI is protective against free wall rupture, likely because of the reduction in hemorrhagic transformation of the infarcted myocardium.…”

“…374,382,383,385 Primary PCI is protective against free wall rupture, likely because of the reduction in hemorrhagic transformation of the infarcted myocardium. 384 Although the incidence of free wall rupture is low, complicating <1% of AMI and representing 1.4% of AMI-associated CS, it carries a 55% to 60% mortality rate and is the second most common cause of death after left ventricular pump failure following AMI. 354,374,[382][383][384] Most cases of free wall rupture occur within 1 week of AMI.…”

“…384 Although the incidence of free wall rupture is low, complicating <1% of AMI and representing 1.4% of AMI-associated CS, it carries a 55% to 60% mortality rate and is the second most common cause of death after left ventricular pump failure following AMI. 354,374,[382][383][384] Most cases of free wall rupture occur within 1 week of AMI. 384 Free wall rupture often presents dramatically, with abrupt development of electromechanical dissociation and asystole, sometimes immediately preceded by recurrent chest pain and ST-segment elevation on ECG.…”

Contained rupture of left ventricular false aneurysm after acute myocardial infarction secondary to left anterior descending artery embolism

“…Left ventricular free wall rupture is a rare complication of acute MI and accounts for 15% to 30% of fatalities (1). Pseudoaneurysm is a variety of left ventricular rupture whereby the pericardium seals the defect, making the wall of the pseudoaneurysm.…”