MioAtlas
G8: Complications of myocardial infarction

Left ventricular free wall rupture

Catastrophic mechanical complication of transmural acute myocardial infarction characterized by complete rupture of necrosed ventricular myocardium into pericardial space, causing acute tension hemopericardium, severe cardiac tamponade, cardiogenic shock, and electromechanical dissociation.

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Definition

Hyperacute and catastrophic mechanical complication of transmural myocardial infarction produced by complete necrotic tearing of left ventricular free wall, causing immediate massive hemorrhagic extravasation into pericardial cavity (tension hemopericardium), acute cardiac tamponade, obstructive shock, and electromechanical dissociation (pulseless electrical activity - PEA) [C9] [G810-02] [G810-03].

Severity criteria

  • Literal statement from study of Figueras et al. [G810-02, Abstract]:
    • «The reliability of electromechanical dissociation (EMD) in diagnosing acute left ventricular free wall rupture (LVFWR) was assessed in 479 consecutive patients with acute myocardial infarction»
  • Literal statement from cardiac rupture cohort study [G810-03 / C9, Abstract]:
    • «Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period»
  • Hemopericardium and pressures: Acute accumulation of blood in pericardium with equalization of diastolic pressures and cardiac tamponade [C9] [G810-02].
  • Arterial pressure: Extreme hypotension (SBP < 70 mmHg) or hemodynamic collapse [C9] [G810-02].

Findings by layer

Hemodynamics

  • Collapse of cardiac output (cardiac output < 2.0 L/min) [C9] [G810-02].
  • Mean right atrial pressure markedly elevated (≥ 18–20 mmHg) and equalized to ventricular filling pressure [C9].
  • Systolic blood pressure: plunge to critical shock (< 70 mmHg) [C9].

Rhythm

  • Initial rhythm with sinus tachycardia, evolving to electromechanical dissociation / pulseless electrical activity (PEA), where electrical activity persists on monitor without effective mechanical ventricular contraction [C9] [G810-02].

ECG

  • Pathological transmural Q waves of acute infarction (infarct Q waves), diffuse low voltage of QRS complexes (low voltage) secondary to hemopericardium, and possible electrical alternans [C9] [E1].

Heart sounds and murmurs

  • Heart sounds: Markedly muffled or inaudible heart sounds (classic Beck triad: muffled sounds, hypotension, and jugular venous distension) [C9] [G810-02].
  • Murmurs: Typically absent (free wall rupture drains into pericardial sac without generating its own intracavitary murmur) [C9].

Arterial pulse

  • Thready pulse practically imperceptible or absent; if measurable pressure is maintained, severe pulsus paradoxus (> 10 mmHg) [B4] [B5] [C9].

Jugular venous pulse

  • Massive jugular distension; 'x' descent present with 'y' descent absent or blunted (absent y descent), characteristic of acute tamponade [B3] [C9].

Maneuvers

  • Not performable due to cardiovascular collapse.

Simulator severity grades

Simulator severity grades: Single grade
Baseline rhythm: Sinus Tachycardia

Also known as: Left ventricular free wall rupture · Post-infarction free wall rupture · Myocardial free wall rupture · LV free wall rupture · LVFWR

Other pathologies in this group

Sources

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [B5] Pulsus paradoxus . Eur Respir J (2013) . DOI: 10.1183/09031936.00138912 PubMed: 23222878
  4. [C9] Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association . Circulation (2021) . DOI: 10.1161/CIR.0000000000000985 PubMed: 34126755
  5. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  6. [G810-02] Reliability of electromechanical dissociation in the diagnosis of left ventricular free wall rupture in acute myocardial infarction . Am Heart J (1996) . DOI: 10.1016/s0002-8703(96)90165-9 PubMed: 8615302
  7. [G810-03] Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period . Circulation (2008) . DOI: 10.1161/CIRCULATIONAHA.108.776690 PubMed: 19064683