Medical management of selected patients with left ventricular free wall rupture during acute myocardial infarction

Unitat Coronaria, Hospital General Vall d'Hebron, Barcelona, Spain.

OBJECTIVES: This study sought to evaluate the effects of prolonged rest and blood pressure control on survival of patients in whom left ventricular free wall rupture (LVFWR) was strongly suspected. BACKGROUND: Left ventricular free wall rupture in myocardial infarction is often fatal, and only a few patients may undergo operation. However, survival without surgical repair has not yet been evaluated. METHODS: Eighty-one consecutive patients with a first transmural acute myocardial infarction in Killip class I or II who presented with acute hypotension due to cardiac tamponade, with electromechanical dissociation (EMD) in 72, were prospectively evaluated. Patients with early recovery were managed with prolonged bed rest and blood pressure control with beta-blockade as tolerated. RESULTS: Forty-seven patients died within 2 h of acute tamponade, and autopsy in 21 showed LVFWR in all. In 15 others, an emergency surgical repair resulted in 2 survivors. The remaining 19 patients, 10 with EMD, had early recovery with dobutamine and colloid solution, and 15 required pericardiocentesis. Shortly thereafter, these 19 patients still showed a paradoxic pulse > or = 20 mm Hg, relevant pericardial effusion (24 +/- 7 mm [mean +/- SD]) and comparable elevation of right and left ventricular filling pressures (15.8 +/- 3.9 and 15.9 +/- 3.8 mm Hg, respectively). Subsequent management included bed rest (8.2 +/- 4.8 days) and control of systolic blood pressure (< or = 120 mm Hg) with beta-adrenergic blocking agents as tolerated (n = 12). Four patients died, and autopsy in three revealed a rupture that was sealed in two. A sealed rupture was also seen at thoracotomy in 2 other patients who, like the remaining 13, survived for 52.5 +/- 35.2 months. CONCLUSIONS: Long-term survival of selected patients with prompt hemodynamic recovery after LVFWR is possible without surgical repair. Prolonged bed rest and blood pressure control are likely to contribute favorably to their initial outcome.

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