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Myocardial rupture
From WikEM
Contents
Background
- Rupture includes defects in the atria, ventricles, or junctions of major vessels
Etiology
- Myocardial infarction – “Softening” of myocardium[1]
- 1.7% of MI patients
- Typically occurs 24-48h post-MI (can be 3-5d if MI was untreated)
- Rupture in the setting of MI is nearly 100% fatal[2]
- Trauma – blunt and penetrating trauma
- Penetrating trauma tends to affect RV
- RV 43%, LV 23%, RA 13%, LA 11%, Pericardium alone 10%[3]
- Infection – Endocarditis and myocardial necrosis[4]
- Rare
- Iatrogenic – Pacer wire placement[5]
- Tend to be small perforations which rarely lead to tamponade or hemodynamic consequences
Clinical Features
- Chest pain, shortness of breath
- Obvious chest injury
- Hypotension
- JVD
- Muffled heart sounds or new murmur or rub
Differential Diagnosis
Chest pain
Critical
- Acute Coronary Syndromes
- Aortic Dissection
- Cardiac Tamponade
- Pulmonary Embolism
- Tension Pneumothorax
- Boerhhaave's Syndrome
- Coronary Artery Dissection
Emergent
- Pericarditis
- Myocarditis
- Pneumothorax
- Mediastinitis
- Cholecystitis
- Pancreatitis
- Cocaine-associated chest pain
Nonemergent
- Stable angina
- Asthma exacerbation
- Valvular Heart Disease
- Aortic Stenosis
- Mitral valve prolapse
- Hypertrophic cardiomyopathy
- Pneumonia
- Pleuritis
- Tumor
- Pneumomediastinum
- Esophageal Spasm
- Gastroesophageal Reflux Disease (GERD)
- Peptic Ulcer Disease
- Biliary Colic
- Muscle sprain
- Rib Fracture
- Arthritis
- Chostochondirits
- Spinal Root Compression
- Thoracic outlet syndrome
- Herpes Zoster / Postherpetic Neuralgia
- Psychologic / Somatic Chest Pain
- Hyperventilation
- Panic attack
Workup
- 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.
Authors
Neil Young, Ross Donaldson, Michael Holtz, Daniel Ostermayer
