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 complication 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 replacement 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 hemopericardium, 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, observation 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