Background

Myocardial rupture refers to the splitting of the heart muscle, especially the myocardium. It is a middle layer of the heart wall. It is responsible for the pumping action of heart.  

Myocardial rupture is a serious condition that can lead to complications like cardiac tamponade. In this condition, blood accumulates in the pericardial sac and compresses the heart.  

The Common causes include heart attacks. In heart attack, blood flow is blocked and that lead to cell death. Myocardial rupture is a rare but serious condition. The diagnosis and intervention are necessary for the best result. 

Epidemiology

Myocardial rupture occurs in a small percentage of cases like 1 to 3%. This condition is associated with myocardial infarction mainly ST-segment elevation myocardial infarction (STEMI). 

The variation factors include age and gender. Elder people whose age is above 60 years are at a high risk of this disease. Some studies also suggest that males are at more risk than compared to females. 

Anatomy

Pathophysiology

Myocardial rupture is commonly seen in heart attacks. It is occurred due to coronary arteries blockage when the heart muscle receives insufficient blood flow. The lack of oxygen and nutrients can cause ischemia and necrosis of the damaged cardiac tissue. 

In response to this condition, body begins an inflammatory response that remove dead and damaged tissue. This process brings immune cells and release of inflammatory mediators. The inflammatory response and breakdown of necrotic tissue can weaken he affected myocardium. The weakened myocardium, inflammation, and changes in tissue structure can lead to the rupture of the ventricular wall. It occurs in various locations in heart like free wall or the septum. 

Etiology

Myocardial rupture can occur due to physical trauma, inflammation, infections, and certain medications. Physical trauma can cause a tear in the heart muscle. Inflammatory conditions like myocarditis weaken the myocardium. This can increase the risk of myocardial rupture. 

Infections which can cause inflammation can also lead to structural damage. Thrombolytic agents used in myocardial infarction treatment can increase bleeding and hemorrhage risk. This all can contribute to the myocardial rupture. 

Genetics

Prognostic Factors

Myocardial rupture is associated with significantly high death rate. The prognosis is very poor. The result of a myocardial rupture depends on factors like the etiology, level of damage, location, and time of intervention. 

Clinical History

Patients who have a history of myocardial infarction or other cardiac issues are at a higher risk of myocardial rupture. The common symptoms are like severe chest pain, difficulty breathing, tachycardia, low blood pressure, shock symptoms, and Beck’s triad if cardiac tamponade is present. 

A shock may lead to symptoms like cold, clammy skin, confusion, and a weak pulse. Myocardial rupture occurs within a few days of a myocardial infraction. It starts within 24 to 72 hours. The duration of symptoms can vary. Some patients may have acute or severe symptoms. Others have progressive symptoms.  

Physical Examination

Information of physical examination in a patient with myocardial rupture can differ based on the location and extent of rupture. Severe and sudden chest pain may be present. This condition is different from chain pain during heart attack. Abnormally fast heart rate, low blood pressure, and pulsus paradoxus also affect the physical examinations.  

An abnormally fast heart rate observes when the heart adjusts for reduced cardiac output. Low blood pressure occurs due to decreased heart function and blood loss into the pericardial sac. Pulsus paradoxus is an excessive decrease in blood pressure after inhalation that is associated with cardiac tamponade. During inhalation, the systolic blood pressure in decrease by more than 10 mmHg. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Acute Coronary Disease 
• Pneumothorax  
• Pulmonary Embolism  
• Cardiac Tamponade  
• Myocarditis  
• Aortic Dissection 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment of myocardial rupture is a critical and an urgent medical issue. It needs an immediate attention. The treatment may vary depending on the type of rupture, associated disease or complications, and general clinical condition of patient. 

Immediate Stabilization 

Initial treatment focus on stabilizing the patient, shock management and maintain the sufficient oxygen and hemodynamic support. An emergency echocardiogram is performed. It confirms the location and extent of rupture, associated disease or complications like pericardial effusion or cardiac tamponade. 

Surgical Interventions 

The surgical treatment depends on the location and type of the rupture. Free wall rupture can be repaired surgically by stitching the tear or using a pericardial or synthetic patch. For septal rupture, patch repair or various techniques can be used. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Administration of Inotropic Agents

Dobutamine 

Dobutamine is a synthetic catecholamine. It contains β1-adrenergic agonist activity. It increases myocardial contractility and heart rate. It is used in patients with myocardial rupture and cardiac shock. It improves the cardiac function and perfusion of tissue.

Milrinone 

Milrinone is a phosphodiesterase-3 inhibitor. It increases intracellular cyclic adenosine monophosphate (cAMP) levels in cardiac myocytes. This can lead to positive inotropic and vasodilatory effects. It is used for patients with myocardial rupture who have pulmonary hypertension or right heart dysfunction.   

Epinephrine 

Epinephrine is a non-selective adrenergic agonist. It acts on alpha and beta receptors. It increases myocardial contractility, heart rate and systemic vascular resistance. This leads to increase in cardiac output and blood pressure. It is used in patients who have cardiac shock or cardiac arrest. 

Administration of Vasopressors

Norepinephrine 

Norepinephrine is a α-adrenergic agonist. It increases systemic vascular resistance and blood pressure. It preserves coronary perfusion pressure. It is used as a first line vasopressor. It is used in septic shock, cardiac shock, and myocardial rupture.  

Phenylephrine 

Phenylephrine is a selective α1-adrenergic agonist. It increases systemic vascular resistance. It is used to support blood pressure in patients with myocardial rupture who have vasodilatory shock or hypotension.  

Vasopressin 

Vasopressin is an endogenous hormone. It acts on V1 receptors in vascular smooth muscle. This can lead to vasoconstriction and increase systemic vascular resistance. It is used as an adjunctive vasopressor in refractory shock including shock associated with myocardial rupture.  

Surgical Intervention

Pericardial Patch Repair 

Pericardial patch repair involves direct surgical treatment to repair the myocardial rupture. It uses a patch made of synthetic material or pericardium of patient. The goal of this method is to stop myocardial rupture from happening again. It restores the structural integrity of the heart wall.  

Pericardiocentesis

Pericardiocentesis is performed in medical emergency. It relieves the pressure on the heart which is caused by a large pericardial effusion. In this procedure, a needle or catheter is inserted into a pericardial sac to remove accumulated fluid. Pericardiocentesis can stabilize the patient temporarily while definitive surgical repair planning occurs on the other side.  

Medication

Future Trends

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References

Myocardial Rupture – an overview | ScienceDirect Topics