Cardiovascular Journal of Africa: Vol 23 No 3 (April 2012) - page 75

CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 3, April 2012
AFRICA
e13
Discussion
Among the mechanical complications of acute MI, acute or
sub-acute LVFWR is serious and often lethal. The prevalence
of LVFWR among patients who die of STEMI is relatively high
(14–26%); however, the prevalence is much lower when all
STEMI patients are included.
The risk factors for LVFWR are identified in several studies
and include: absence of previous history of angina or MI, absence
of collateral blood flow, infarct size, persistent ST-segment
elevation, recurrent or persistent chest pain, age over 70 years,
female gender, and anterior location of MI.
1,2
The most common
site of rupture is the anterior or lateral aspect of the ventricular
free wall. Isolated posterior infarction is uncommon and inferior
wall infarction is unusual unless associated with infarction of the
lateral or posterior wall.
3
The type of reperfusion therapy will also affect the risk of
cardiac rupture. Early thrombolytic therapy (within six hours
of onset of symptoms) has been shown to reduce the risk of
cardiac rupture. Late thrombolytic therapy seems to accelerate
the occurrence of cardiac rupture, but not its prevalence.
4
Although clinical guidelines allow the performance of ETT in
stable post-MI patients to assess the extent of residual ischaemia,
using a submaximal stress test three to five days after MI,
there are some reports of LVFWR during ETT or a few days
thereafter.
3,5
In our case, one possibility was that performing an
early and ‘over-submaximal’ ETT in the setting of SK infusion
after re-infarction may have promoted myocardial rupture.
The clinical picture of LVFWR is diverse. Acute rupture of
the left ventricle usually results in haemopericardium and cardiac
tamponade, leading to death. Emergency pericardiocentesis
confirms the diagnosis and temporarily relieves the
haemodynamic instability. In sub-acute rupture, the defect
is occluded by an organised thrombus and the pericardium.
It presents with recurrent or persistent chest pain, nausea,
agitation, sudden hypotension and ECG manifestations of
localised pericarditis.
Suspicious myocardial rupture necessitates emergency
bedside echocardiography; the presence of pericardial effusion
must persuade the physician to do pericardiocentesis. A bloody
aspirate must be followed by emergency cardiac surgery.
Meanwhile, stabilising the patient’s haemodynamic status with
any, or a combination of the following measures is the rule:
intravenous fluid administration, blood transfusion, inotropic and
vasopressor support, continued pericardiocentesis or intra-aortic
balloon pump insertion. Timely management is associated with
improved survival, especially in sub-acute ruptures.
Conclusion
In recent years, there have been increasing reports of patients
surviving after LVFWR. To our knowledge, there is no report
of auto-transfusion as a life-saving measure. This innovative
measure saved time for our moribund patient and allowed him
to recover. Another interesting aspect of this case report is the
patient’s unusual ventriculography, which shows a rupture in the
inferior wall of the left ventricle with contrast media entering
into the pericardial sac.
References
1.
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rupture: clinical presentation and management.
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Moreno R, Lopez-Sendon J, Garcia E,
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Cardiol
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Weinberg L, Kandasamy K, Evans SJ,
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Becker RC, Charlesworth A, Wilocox RG,
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1...,65,66,67,68,69,70,71,72,73,74 76,77,78,79,80,81
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