Left ventricular free wall rupture
Left ventricular free wall rupture is a catastrophic mechanical complication of myocardial infarction in which the infarcted wall ruptures into the pericardium, causing hemopericardium, tamponade, and frequently sudden pulseless electrical activity and death days after an infarct. A contained rupture forms a pseudoaneurysm; diagnosis is by urgent echocardiography, and survival requires immediate pericardiocentesis and emergent surgery.
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What this article covers
- Overview
Definition: left ventricular free wall rupture is transmural rupture of infarcted ventricular wall into the pericardial space.
- Epidemiology
Rare and often fatal, a leading cause of early post-MI death outside the hospital.
- Risk factors
Large, transmural, first infarct without collateral protection.
- Pathophysiology
Wall necrosis and rupture: softened infarcted myocardium tears, usually around day 3 to 5.
- Clinical features
Sudden collapse: abrupt loss of pulse with pulseless electrical activity or cardiac arrest.
- Differential diagnosis
Ventricular septal rupture: shunt murmur and biventricular failure, distinguished by an oxygen saturation step-up on right heart catheterization rather than hemopericardium (mechanical complications of MI).
- Diagnosis
Establish with urgent echocardiography showing pericardial blood with tamponade or a pseudoaneurysm: the diagnostic basis is echocardiography demonstrating hemopericardium with tamponade physiology…
- Management
First-line, decompress and support immediately: emergent pericardiocentesis to relieve tamponade as a temporizing measure, then give IV crystalloid and vasopressors (norepinephrine 0.05 to 0.5…
- Complications
Sudden cardiac death: the most common outcome of acute rupture.
- Prognosis
Very poor for acute rupture: frequently fatal before intervention.
- Prevention
Timely reperfusion of STEMI to limit transmural necrosis.
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Related articles
- Mechanical complications of myocardial infarction
Mechanical complications of myocardial infarction are catastrophic structural ruptures, papillary muscle rupture, ventricular septal rupture, and free-wall rupture, occurring days after a usually large, late-reperfused infarct and presenting as abrupt hemodynamic collapse, often with a new murmur. Diagnosis is by urgent echocardiography, and survival depends on hemodynamic stabilization and emergent surgical repair.
- Cardiac tamponade
Cardiac tamponade is life-threatening compression of the heart by a pericardial effusion, impairing diastolic filling and cardiac output. It presents with hypotension, distended neck veins, and pulsus paradoxus, is confirmed by echocardiography, and is treated by urgent pericardiocentesis; avoid vasodilators and aggressive diuresis.
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