The rupture of the free heart wall is one of the mechanical complications of myocardial infarction. It is an extremely dangerous condition for the patient's life. Fortunately, it is now relatively rare. The decrease in the incidence of cardiac rupture is mainly related to the significant development of invasive infarction treatment and cardiac surveillance. What are the causes of a free wall crack? Can you predict them? How is it manifested? How is the treatment?

The rupture of the free heart wallis an extremely dangerous complication of myocardial infarction. Due to the progress of invasive infarction treatment and the development of cardiac surveillance, it is now relatively rare. However, progress in this area has not reduced the risk to zero, which is why diagnostic vigilance is so important, which will enable quick action and increase the patient's chance of survival.

Crack in the free wall of the heart - causes

A heart attack is a necrosis of the heart muscle caused by ischemia. The area of ​​the heart affected by the infarction as being mechanically "weaker" and less durable is therefore a potential rupture site. Most often it occurs on average in 3-5. the day after the heart attack. During healing, the tissue is reorganized and dead muscle fibers are lysed, and the infarcted area is relatively soft.

A rupture of the heart wall is most often considered a complication of myocardial infarction, but there are several other reasons for this clinical condition:

  • penetrating or blunt cardiac trauma;
  • iatrogenic damage: e.g. during implantation of implantable devices or open cardiac surgery (rarely);
  • primary and secondary heart cancers;
  • infective endocarditis;
  • aortic dissection.

Rupture of the free wall of the heart - risk factors

The cracks in the free wall of the heart entangling an infarction cannot be predicted. However, there are a number of factors that statistically increase the risk of its occurrence. These include:

  • over 60,
  • female gender,
  • high blood pressure values ​​(especially in the first 24 hours after a heart attack),
  • first episode of myocardial infarction,
  • full-sided infarction (necrosis covers the full thickness of the ventricular muscle),
  • supply of non-steroidal anti-inflammatory drugs / glucocorticosteroids,
  • delayed admission to hospital (>12-24h).

Increased risk is also associated with the treatment of infarction through the use of the so-called fibrinolytic treatment when drugs are administered intravenously to "dissolve" the clot from a ruptured plaque. This is especially true of patients whose diagnosis of infarction was delayed (>11h).

Currently, due to the widespread availability of PCI (percutaneous coronary intervention), fibrinolysis is only an alternative that is rarely performed in practice. This is one of the reasons why we are dealing with a reduction in the frequency of free wall fractures in the course of an infarction.

Contrary to risk factors, we can distinguish several clinical situations in which rupture of the free wall is less likely (not necessarily favorable for the overall prognosis and cardiovascular risk):

  • ventricular hypertrophy - is the result of prolonged arterial hypertension; thicker chamber wall, less risk of perforation;
  • previous infarcts - post-infarction scars reduce the risk of rupture;
  • longer-lasting ischemic heart disease - development of collateral circulation, which contributes to the reduction of the ischemic area during the infarction.

Rupture of the free heart wall - symptoms

Clinical symptoms of myocardial rupture depend on the mechanism and location of the damage, as well as on its haemodynamic consequences. We can divide them according to the time of occurrence:

  • early - develops in the first 48 hours,
  • late - occurs after 48 hours (usually results from widening of the infarcted area).

The course of a post-infarction rupture does not always look the same. We can isolate the crack:

  • sharp,
  • subacute

A sharp fracture is very violent. The symptoms of acute heart failure and cardiogenic shock come to the fore, such as:

  • shortness of breath, shortness of breath (usually as a consequence of pulmonary edema);
  • tachycardia;
  • pale, cool, sweaty skin;
  • loss of consciousness.

This is due to a massive hemorrhage into the pericardial sac surrounding the heart, which leads to the formation of the so-called cardiac tamponades. Increased pressure within the confined space of the pericardial cavity places a heavy pressure on the walls of the heart and impairs ventricular filling. Its basic,the characteristic symptoms are:

  • overcrowded jugulars,
  • muted heart sounds (in auscultation),
  • hypotension (low blood pressure),
  • paradoxical pulse - reduction of pulse filling with an accompanying decrease in systolic pressure by more than 10 mmHg during inspiration,
  • nonspecific chest pain.

Tamponade of the heart, if left untreated, can lead to cardiac arrest very quickly in the mechanism of the so-called electromechanical disconnection.

In the case of a subacute rupture of the free heart wall, symptoms develop more slowly (it may even be asymptomatic!). This can happen when the crack is small.

Rupture of the free wall of the heart - diagnosis

The fact that there has been a mechanical complication, which is a rupture of the heart wall, may be evidenced by symptoms and sudden deterioration of the clinical condition of a patient who has suffered an infarction, e.g. a sudden drop in blood pressure.

The medical history and physical examination as well as non-specific changes in the ECG examination may only suggest and arouse suspicion. The test of choice that will confirm the diagnosis is the ECHO test, i.e. echocardiography. It allows you to recognize the features of a tamponade with great sensitivity and thus make a final diagnosis.

Rupture of the free heart wall - treatment

The first step in the event of tamponade is to perform urgent pericardiocentesis, i.e. percutaneous puncture of the pericardial sac in order to decompress it by evacuating blood. Equally important is adequate anti-shock treatment, the essential elements of which are the supply of fluids and the use of drugs, e.g. dobutamine, to improve cardiac output.

Circulatory stabilization is necessary to perform a repair surgery that is crucial for the patient's life. Cardiac surgery intervention gives the patient a real chance of survival. The procedure involves resection of the necrotic area and then closing the defect with a Teflon or Dacron patch attached to the epicardium.

Category:

Cardiology