The CardioNerds Five – Free Wall Rupture
This infographic explores the critical aspects of free wall rupture (FWR), a rare but life-threatening mechanical complication of myocardial infarction (MI). It breaks down essential topics and clinical considerations:
What’s the role of revascularization when presenting with late STEMI?
- The benefit of revascularization depends heavily on the duration of ischemia and the relationship to infarct size. However, this benefit diminishes for patients presenting late after a STEMI. Findings from the Occluded Artery Trial (OAT) indicate that revascularization in hemodynamically stable patients presenting 3-28 days after MI does not improve outcomes. Therefore, PCI of a totally occluded infarct-related artery is not recommended >24 hours post-STEMI unless the patient is experiencing ongoing ischemia.
What are some causes of acute hemorrhagic pericardial effusion?
- While traditional causes like infection are common, some causes of hemorrhagic effusion, including iatrogenic injury (e.g., during cardiac surgery or catheterization), require urgent evaluation. Other causes include free wall rupture, pseudoaneurysm, aortic dissection, and trauma.
What are the risk factors for free wall rupture (FWR) after an MI?
- Though rare in the reperfusion era, FWR carries a high mortality risk. It typically occurs within 2 weeks of MI. Risk factors include first MI, poor collateralization, delayed reperfusion, older age, female sex, and persistent ST-elevation. Clinical signs may include cardiac tamponade and sudden cardiovascular collapse.
When should you pursue surgical management acutely for tamponade?
- When tamponade develops, urgent drainage of pericardial fluid is essential to prevent hemodynamic collapse. Surgery is often necessary for cases involving traumatic hemopericardium, aortic dissection-related hemopericardium, or free wall rupture. Controlled drainage may be used as a temporary measure to maintain SBP >90 mmHg until definitive repair is possible.
What is a ventricular pseudoaneurysm?
- A ventricular pseudoaneurysm forms when a rupture is contained by the surrounding pericardium or thrombus, without any myocardial tissue in the outpouching. Unlike true aneurysms, pseudoaneurysms have a high propensity to rupture. They typically present with a narrow neck and require urgent surgical management.
Produced by Dr. Eunice Dugan and Dr. Karan Desai
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