Complicated acute myocardial infarction: free wall rupture

Abstract

The rupture of the ventricular wall complicates 1- 3% of the patients suffering from acute myocardial infarction. On necroptic studies the percentage raises up to 7-24%. The risk factors are age>60 years, feminine gender and hypertension. The acute ruptures are characterized by shock through cardiac tamponade. The subacute ruptures are a challenge for surgeons; immediate postoperatory death varies between 0 to 60%. Death without surgery occurs in 100% of the cases. A 73 years old male patient is admitted to the hospital for intermittent claudication at 15-20m, with insignificant heredocolaterale history, smoker for approximately 60 years 1 package per day. The patient has no cardiological history. After his admission he presented syncope. The clinical exam showed turgescent jugular veins, diffuse abdominal pain, and the lower liver margin was palpable 2 cm under the right costal margin. Differential diagnosis was: mesenteric ischemia, cardiac tamponade and aortic dissection. The transtoracic echocardiography showed the presence of pericardial liquid of 25 mm in the right ventricle, an intrapericardial thrombus in the left ventricle. The final diagnosis is acute anteroapical myocardial infarction with cardiac rupture, intrapericardial thrombus, pericardial tamponade and obliterant arteriopathy of the inferior limbs, stage III. The patient was transferred to the Cardiology Center in Iasi and after the necessary investigations went directly to the operating room due to the mechanical complication of the infarction. The postoperatory evolution was good. The particularities of the case consist of: the sudden debut through the rupture of the myocardium without the typical retrosteral pain; the lack of EKG or the necrosis enzymes modifications and the good postoperatory evolution.