Myocardial ruptures: causes, symptoms, diagnosis, treatment

The frequency of ruptures of the free wall of the left ventricle in myocardial infarction is from 1% to 4%, it is the 2nd cause of death of patients in hospital (after cardiogenic shock), and at autopsy, ruptures of the free wall of the heart are detected in 10-20% of the deceased. Clinically, three variants of the course of rupture of the free wall can be distinguished:

1. A sudden increase in central venous pressure (CVP) and a drop in blood pressure with loss of consciousness - acute hemotamponade. Death occurs within a few minutes. This variant is the most common. False electromechanical dissociation is often observed: ECG registration without a pulse, since blood during systole enters not the aorta, but the pericardial cavity.
2. Subacute course - within a few hours with a clinical picture of cardiac tamponade (“slow myocardial rupture”).
3. The least common is a rupture of the free wall with the formation of a so-called pseudoaneurysm (without hemopericardium). In this case, subpericardial hemorrhage occurs only at the site of the myocardial rupture.

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

In the case of a subacute course, it is possible to perform echocardiography, pericardiocentesis and surgical intervention. Temporary relative stabilization of hemodynamics (for about 30 minutes) can be achieved by infusion of fluid in combination with the introduction of dobutamine and/or dopamine. In case of bradycardia, atropine is prescribed.

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

Rupture of the interventricular septum occurs in 1-2% of patients, more often with anterior myocardial infarction. In most cases, acute right ventricular failure (swelling of the jugular veins, severe dyspnea) develops suddenly, less often pulmonary edema or cardiogenic shock. A coarse pansystolic murmur appears with a maximum near the lower part of the sternum on the left, and a tremor is often palpated. In approximately 1/3 of patients, an AV block or a block of the branches of the His bundle (more often a block of the right leg) appears on the ECG.

The diagnosis of ventricular septal rupture is confirmed by echocardiography. During catheterization of the right heart, a difference in blood oxygen saturation is noted 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).

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Treatment of myocardial rupture

Treatment of myocardial rupture is surgical. Immediate surgery is necessary, since even with a relatively stable hemodynamic state, an increase in the size of the septal rupture is often observed. Mortality 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 with papillary muscle rupture, vasodilators are prescribed, often in combination with dopamine or dobutamine, and intra-aortic counterpulsation. The introduction of an intracardiac "umbrella" using cardiac catheterization for temporary closure of the defect has been described.