Cardiac Rupture: Work Quickly, Head for the Surgical Suite

Cardiac rupture can occur after several medical emergencies, with blunt chest injury, penetrating chest wounds and acute myocardial infarction (AMI) leading causes. It may be an iatrogenic occurrence during percutaneous cardiac procedures (including device implantation) or open-heart surgery (particularly valve replacement).

Patients are very likely to die unless physicians identify the rupture early and provide urgent surgical intervention. The incidence of cardiac rupture has decreased over the last 30 years, paralleling increased use of primary percutaneous coronary intervention (PPCI) and improved AMI management approaches. It is now rare.

The journal Cardiology has published a study ahead-of-print that describes the changing nature of cardiac rupture. The primary change in AMI treatment has been the tendency to use PPCI rather than fibrinolytic therapy whenever possible. This has reduced a major risk factor for myocardial rupture.

This study examined 2,380 patients admitted with AMI between 2008 and 2015, and found that 12 had experienced cardiac rupture. None were treated with thrombolytic therapy.

Older patients were at the highest risk with a mean age of 78-years-old. Ten of the 12 patients presented to the emergency department with pericardial effusion. Seven patients underwent coronary

angiography, and 4 underwent PPCI.

Six patients underwent and survived surgery. The investigators compared the results of this study with their previous work on the subject, and noted this is a significant improvement from results gathered between 2000 and 2003.

Older patients (age ≥ 90 years), who were cognitively impaired or had dementia tended to be treated more conservatively. All patients who were treated conservatively died due to rupture, but the investigators report that there have been cases where patients treated conservatively have survived. They recommend reserving conservative management for patients who are too old, frail or cognitively impaired to undergo surgery.

The investigators conclude that comprehensive echocardiographic examination (to identify pericardial effusion), PPCI and immediate surgery seem to lessen risk of myocardial rupture, but mortality remains high.