Left Ventricular Free Wall Rupture - An Insight

Introduction

One uncommon but potentially dangerous side effect of acute myocardial infarction (AMI) is left ventricular free wall rupture (LVFWR). A blood clot may, in rare cases, close the defect and cause a ventricular pseudoaneurysm to develop in the subacute form, which is less deadly. To diagnose, one must have high suspicion and closely observe the patient's symptoms and indicators. The gold standard for conclusive detection of AMI complications like left ventricular free wall rupture is urgent transthoracic echocardiography (TTE). If the diagnosis is uncertain or to rule out other hemopericardium aetiologies, Multi-Detector computed tomography (MDCT) is a good substitute.

When a patient is stable and has either a pseudoaneurysm or subacute LVFWR, cardiac magnetic resonance imaging (CMR) is mostly utilized to provide more precise tissue characterization. When a surgical repair is being prepared, hemodynamically unstable patients may have pericardiocentesis as a last resort. This is not a routine treatment. Treatment for left ventricular fibrillation with ventricular wall reconstruction or, less commonly, infarctectomy with patch implantation is still the rule for immediate surgical repair despite the high rates of surgical death.

What Is the Free Wall of the Left Ventricle?

The portion of the left ventricle wall that is not attached to the apex and is not in touch with the interventricular septum is known as the "free wall of the left ventricle." The free wall is posterior and lateral when in an attitudinally proper posture.

What Are the Types of Ventricular Free Wall Rupture?

The following are the types of ventricular free wall rupture:

A full or partial LV (left ventricle) free-wall rupture is possible.

• A whole rupture results in hemopericardium and cardiac tamponade, which causes abrupt death.

• On the other hand, incomplete rupture can happen when the pericardium and an organized thrombus close the ventricular hole, creating a ventricular PSA.

A cardiac attack that seriously damages the heart may result in a ventricular rupture. People who are at a higher risk of experiencing ventricular rupture are

• Possess a high pulse rate.

• Experience recurrent chest discomfort.

• Before visiting a hospital, wait a lengthy period following the onset of chest discomfort.

• A person who is suffering from an initial heart attack.

• Surpass 60 years of age.

• Possess several blood arteries that are atheroscid.

• Possess cardiac failure.

• Stroke.

• Have a chronic renal illness.

What Happens With a Ruptured Heart?

It is dependent on the location of the rupture.

• An overabundance of blood can enter the lungs due to a breach in the septum, the wall between the two ventricles, and the heart's lower chambers. This results in breathing difficulties, respiratory failure, and an accumulation of fluid in the lungs (edema). Heart failure develops quickly from a rupture in the mitral valve muscle because blood leaks backward instead of being pushed regularly out of the body.

• The most frequent kind of rupture is the free (outside) heart wall, which can be dangerous because blood can leak into the chest from the heart's exterior.

What Causes Ventricular Free Wall Rupture?

Post-acute myocardial infarction is the most frequent cause of left ventricular rupture. The absence of a previous history of angina or myocardial infarction, ST elevation in the first EKG, peak CK-MB greater than 150 IU/L (International Unit per liter), female sex, age over 70, anterior location, transmural infarction, and first infarction are risk factors linked to left ventricular free wall rupture. A correlation exists between an elevated risk of free wall rupture and a 10 mm (millimeter) or greater pericardial effusion. Conversely, there is a protective effect from LV (left ventricular) hypertrophy, congestive heart failure (CHF), prior infarction history, chronic ischemic heart disease, early beta-blocker treatment after myocardial infarction, and prompt intervention.

Iatrogenic Causes Encompass:

• Blunt or penetrating trauma from diagnostic catheterization.

• Balloon valvuloplasty.

• Transcatheter aortic valve replacement (particularly transapical approach).

• Pericardiocentesis.

• Implantation of temporary or permanent pacing catheters.

• A myocardial abscess rupture can happen when an infection like tuberculosis or an echinococcal cyst occurs.

• Infective endocarditis.

• Myocardial rupture can occur in any chamber of the heart due to cardiac tumors, such as lymphoma and acute myeloblastic leukemia.

• Sarcoidosis via transmural noncaseating granulomas is another uncommon etiology.

What Are the Symptoms of Ventricular Free Wall Rupture?

Symptoms of a ventricular rupture might be:

• Ache in the chest.

• Shock from cardiogenesis.

• Cardiac arrhythmia.

• Heart breakdown.

• Respiratory failure or pulmonary edema.

• Tamponade of the heart.

What Are the Treatment Modalities That Are Used to Treat Ventricular Free Wall Rupture?

In the treatment of a left ventricular rupture, surgery is essential, but medication therapy may be helpful. A cardiothoracic surgeon should be consulted as soon as possible. It is necessary to move patients right away to the operating room. It might be necessary to drain the hemopericardium surgically.

Physicians who treat LV-free wall ruptures may recommend intra-aortic balloon pumps. Since there is a chance that pericardiocentesis would exacerbate the rupture, it is largely contraindicated. It is necessary to put patients on bed rest exclusively. As patients get ready for surgery, medical treatment helps them stay stable. Preload was raised, and cardiac output was enhanced by rapid fluid delivery.

The surgical management of a left ventricular free wall rupture involves excising the affected region and sealing it with biological glues, polyester patches, or polytetrafluoroethylene. Even in the absence of symptoms, surgical treatment of pseudoaneurysms is advised due to their high risk of rupture. Depending on their size, associated VSDs are closed via patches. Mitral valve replacement is the course of treatment if there is a concomitant rupture of the papillary muscles.

Conclusion

Acute myocardial infarction can have a potentially fatal mechanical consequence called left ventricular free-wall rupture. The majority of those who experience it have ST-elevation myocardial infarctions. Infections and trauma are two other explanations that must be considered. Hemothorax and cardiac tamponade are the two major consequences of a left ventricular free-wall rupture. Bed rest, blood pressure and heart rate regulation, inotropic support, and avoiding agitation are all part of postoperative care. Care should be taken to avoid the consequences of illness.