Myocardial rupture following acute myocardial infarction

Ten patients, eight males and two females, suffered myocardial rupture following acute myocardial infarction and required surgery. There were five ventricular septal ruptures, four papillary muscle ruptures and one free wall rupture. Ventricular septal rupture was suspected clinically by the appearance of a new systolic murmur, usually associated with a thrill at the left sternal border. A left to right shunt was confirmed by bedside oximetry using a Swan-Ganz catheter. The mean pulmonary to systemic flow ratio was 3.04:1. Following cardiac catheterization all patients underwent corrective surgery with or without aortocoronary bypass grafting. Three patients with inferior wall myocardial infarction died. Papillary muscle rupture was suspected clinically following the abrupt onset of hypotension with severe acute pulmonary edema accompanied by a new systolic murmur. The diagnosis was confirmed by cardiac catheterization. All underwent surgery for mitral valve replacement with or without aortocoronary bypass grafting. One patient died postoperatively of multiorgan failure. Free wall rupture was suspected clinically by the sudden onset of loss of consciousness, apnea, junctional bradycardia and severe hypotension leading to electromechanical dissociation. The diagnosis was confirmed by demonstrating a significant pericardial effusion by two dimensional echocardiography. Immediate surgery was performed. This patient is totally asymptomatic on no drug treatment six months following discharge. Ten patients underwent emergency surgery for myocardial rupture. Operative mortality was 40%. Patients with ventricular septal rupture associated with an inferior myocardial infarction had a poor prognosis.