Myocardial ruptures: causes, symptoms, diagnosis, treatment

The frequency of ruptures of the free wall of the left ventricle with myocardial infarction is from 1% to 4%, this is the second cause of death in hospital patients (after cardiogenic shock), and at dissection, heart breaks in the free wall are revealed in 10-20% of deaths. Clinically, there are three variants of the flow of a free wall break:

1. Sudden increase in central venous pressure (CVP) and a drop in blood pressure with loss of consciousness - acute gemotamponada. Death occurs within a few minutes. This variant is most often encountered. Often there is a false electro-mechanical dissociation: ECG recording without a pulse, the vasculitis during systole enters not into the aorta, but into the pericardial cavity.
2. Subacute flow - for several hours with a clinical picture of cardiac tamponade ("slow-flowing myocardial rupture").
3. The least common is the rupture of the free wall with the formation of the so-called pseudoaneurysm (without hemopericardium). In this case, subpericardial hemorrhage occurs only at the site of myocardial rupture.

Rupture of the free wall usually occurs in the range from the first day to 3 weeks, more often in women, in the elderly, in the presence of arterial hypertension.

With subacute flow, one can do echocardiography, pericardiocentesis and surgical intervention. Temporal relative stabilization of hemodynamics (approximately 30 minutes) can be achieved by fluid infusion in combination with the administration of do-butamine and / or dopamine. With bradycardia prescribe atropine.

Temporal relative stabilization of hemodynamics in acute mitral insufficiency can sometimes be achieved with the help of vasodilators: infusion of nitroglycerin or sodium nitroprusside, taking captopril, in combination with infusion of dopamine or dobutamine. More effective use of intra-aortic balloon counterpulsation.

The rupture of the interventricular septum occurs in 1-2% of patients, more often with anterior myocardial infarction. In most cases, sudden acute right ventricular failure (swelling of the cervical veins, severe shortness of breath), less frequent pulmonary edema or cardiogenic shock. Appears coarse pansystolichesky noise with a maximum near the bottom of the sternum on the left, often palpation there is a trembling. Approximately one-third of patients on the ECG appear AV blockade or blockade branches of the bundle of the Hisnia (more often blockade of the right leg).

The diagnosis of rupture of the interventricular septum is confirmed by echocardiography. When the right heart is catheterized, there is a difference in oxygen saturation between the right ventricle and the right atrium (the oxygen content in the right ventricle and pulmonary artery is greater than in the right atrium by 5% or more).

[1], [2], [3], [4], [5], [6]

Treatment of myocardial rupture

Treatment of myocardial rupture is surgical. An immediate operation is necessary, since even with a relatively stable state of hemodynamics, an increase in the size of the septal rupture is often observed. Mortality rate reaches 25% in the first day, 50% - by the end of the first week and 80% - within a month. For temporary relative stabilization of hemodynamics, as well as with rupture of the papillary muscle, the use of vasodilators is used, often in combination with dopamine or dobutamine, intra-aortic counterpulsation. The introduction of an intracardiac "umbrella" with the help of cardiac catheterization for temporary closure of a defect is described.