Although mortality rates during acute myocardial infarction (AMI) continue to drop, cardiac rupture (left ventricular free wall [LVFW] or ventricular septum [VS] or papillary muscle [PM] or combination) remains relatively common. The aim was to identify commonalities among patients with AMI complicated by cardiac rupture. During a 22-year period (1993-2014) 64 patients hospitalized for AMI were studied and clinical and morphologic variables in those with (25 patients) – vs – those without (39 patients) cardiac rupture were compared, and previous reports on this topic were reviewed. Compared to the non-rupture cases, the rupture group was significantly older (71 years – vs – 60 years); had a much higher frequency of huge deposits of adipose tissue in the heart (floated in formaldehyde) (88% – vs – 20%) but a lower mean body mass index (28.2 Kg/m 2 – vs – 33.2 Kg/m 2 ); a much lower frequency of healed myocardial infarct (scar) (4% – vs – 28%); a lower frequency of diabetes mellitus (24% – vs – 47%), and a higher frequency of thrombolytic therapy during the fatal AMI (32% – vs – 10%). None of the rupture cases had evidence of dilated left ventricular cavities or evidence of heart failure before the AMI complicated by rupture. In conclusion, cardiac rupture appears to account for a high percent of deaths during a first AMI. It most commonly occurs in patients with extremely fatty hearts and in those without evidence of prior heart failure.
During the last 80 years many publications on cardiac rupture complicating acute myocardial infarction (AMI) have appeared ( Table 1 ). Some have compared findings at necropsy in fatal AMI with – vs – without rupture of either the left ventricular free wall (LVFW) or ventricular septum (VS), and others have described only the rupture cases. Many previous publications provided no photographs of the ruptured hearts. One of us (WCR) has been involved since 1967 in a number of studies on cardiac rupture secondary to AMI, including an examination at necropsy of 204 such patients with rupture of the LVFW or VS or papillary muscle (PM) studied from 1968 to 1989. Despite these previous studies commonalities among these 3 types of cardiac rupture during AMI have not been clearly delineated. The present study attempts to fill that void by examining a new series of 25 patients with cardiac rupture studied at necropsy from 1993 to 2014, compares clinical and necropsy findings in them to 37 patients with fatal AMI without rupture, and focuses on commonalities observed in these patients and in previously reported ones.
| Author (Year) [Reference] | No. Patients With Fatal AMI | Rupture Cases | ||||
|---|---|---|---|---|---|---|
| Number Ruptured | Location | M/F | Ages (Years) Range (Mean) | |||
| LV | VS | |||||
| BEFORE CORONARY CARE UNITS | ||||||
| Bean (1938) | 300 | 17 (6%) | 16 | 1 | 8/9 | – |
| Edmonson and Hoxie (1942) | 865 | 72 (8%) | 59 | 13 | 40/32 | 30-90 (-) |
| Friedman & White (1944) | 105 | 10 (10%) | 10 | 0 | 7/3 | 51-80 (66) |
| Diaz-River & Miller (1948) | 53 | 5 (9%) | 4 | 1 | 1/4 | – |
| Wang et al (1948) | 267 | 23 (9%) | 22 | 1 | – | – |
| Selzer (1948) | 95 | 8 (8%) | 7 | 1 | – | – |
| Zinn& Cosby (1950) | 430 | 34 (8%) | 34 | 0 | 12/22 | 54-82 (71) |
| Oblath et al (1952) | 1,026 | 80 (9%) | 80 | 0 | 47/33 | 60-80 (-) |
| Wessler et al (1952) | 124 | 20 (16%) | 15 | 5 | – | – |
| Waldron et al (1954) | 545 | 40 (8%) | 40 | 0 | – | – |
| Goetz & Gropper (1954) | 145 | 14 (10%) | 11 | 3 | – | 56-76 (-) |
| Maher et al (1956) | 183 | 21 (12%) | 19 | 2 | 10/11 | 54-92 (69) |
| Griffith et al (1961) | 1,212 | 52 (4%) | 44 | 8 | – | – |
| Spiekerman et al (1962) | 87 | 21 (24%) | 18 | 3 | 10/11 | – |
| Ross & Young (1963) | 606 | 43 (7%) | 43 | 0 | 27/16 | 35-90 (-) |
| London & London (1965) | 1,001 | 47 (5%) | 42 | 5 | 27/20 | – (69) |
| Sievers (1966) | 811 | 104 (13%) | 104 | 0 | 52/52 | – (69) |
| Sugiura et al (1968) | 50 | 8 (16%) | 6 | 2 | 5/3 | 68-88 (77) |
| Lewis (1969) | 1,228 | 106 (9%) | 106 | 0 | 52/54 | 42-92 (71) |
| Subtotal | 9,133 | 725 (8%) | 680 | 45 | 298/270 | 30-92 (-) |
| (94%) | (6%) | (52%)/(48%) | ||||
| AFTER CORONARY CARE UNITS | ||||||
| Hammer et al (1972) | 47 | 10 (21%) | 7 | 3 | 6/4 | 55-80 (64) |
| Rasmussen et al (1979) | 401 | 64 (16%) | 61 | 3 | 42/30 | 46-90 (-) |
| Dellborg et al (1985) | 329 | 56 (17%) | 51 | 5 | 28/28 | – (71) |
| Hiramori (1987) | 143 | 26 (18%) | 20 | 6 | – | 23-92 (62) |
| Herlitz (1988) | 76 | 32 (42%) ∗ | 32 | 0 | – | – (67) † |
| Reddy & Roberts (1989) | 648 | 204 (31%) ‡ | 137 | 53 | 112/92 | 43-94 (68) |
| Batts et al (1990) | 1,251 | 100 (8%) | 100 | 0 | 51/49 | – (74) † |
| Pollak et al (1994) | 533 | 105 (20%) § | 105 | 0 | – | – |
| Hutchins et al (2002) | 153 | 47 (31%) ‖ | 47 | 0 | 22/25 | 46-97 (70) |
| Markowicz-Pawlus et al (2012) | 270 | 49 (18%) | 49 | 0 | 12/37 | – (70) |
| Subtotal | 3,851 | 693 (18%) | 609 | 70 | 273/265 | 23-97 (-) |
| (90%) | (10%) | (51%)/(49%) | ||||
∗ Study does not specify location of rupture.
† Mean age calculated as a weighted average of ages reported by the authors in separate patient groups.
‡ Five of these patients also had rupture of a left ventricular papillary muscle.
§ One case of rupture diagnosed intraoperatively.
‖ Includes one reported case of right ventricular free wall rupture.
Methods
The 64 patients with fatal AMI were seen at Baylor University Medical Center during a 22-year period (1993-2014). With 3 exceptions (gross photographs studied), all hearts were examined and described by WCR. At necropsy, the presence or absence of hemopericardium was determined by the prosector, most commonly under the supervision of JMG. At necropsy, the hearts were placed unopened in a container of formaldehyde, and after fixation for usually 3 to 5 days the hearts were opened and described by WCR, the specimens were photographed, (usually by JMK), and sections were cut by WCR for histologic study. After excising extraneous (non-cardiac) tissues, all hearts were placed in a container of 10% formaldehyde to see if they floated to the surface after removing any air inside of the cardiac chambers. Nearly all hearts were opened by cutting the ventricular walls parallel to the posterior atrioventricular sulcus at about 1 cm intervals, except for the most apical cut which was about 3 cm in thickness. All hearts were superficially dried with paper towels and weighed on an very accurate scale (to ± 1 g). The atria were incised by a cut about midway between the atrioventricular valve annulae and the most cephalad extension of the atrial walls. The pulmonary trunk was excised about 2 cm cephalad to its sinotubular junction and the ascending aorta about 3 cm cephalad to its sino-tubular junction. At least 4 histologic sections were prepared in each heart. Each was stained by hematoxylin-eosin and by the trichrome method and all sections were examined by WCR and frequently by JMG.
The medical records were obtained in all 64 patients and data in each of the variables listed in Tables 2 and 3 were sought.
| Patient Number | Age | Race | Sex | BMI (kg/m 2 ) | DM | SH | BP Rx | CABG | TT | PCI | LV Scar | Rupture Site | Location of AMI | Interval of Onset MI to Death (Days) | RV Infarct | HW (g) | Float | H | Figure Number |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 68 | W | F | 24.2 | + | 0 | 0 | 0 | + | + | 0 | LVFW | A | 2 | 0 | 375 | + | + | – |
| 2 | 70 | B | F | – | + | + | – | 0 | 0 | 0 | 0 | LVFW | L | 3 | 0 | 405 | 0 | + | 3 |
| 3 | 72 | B | F | – | 0 | + | – | 0 | + | 0 | 0 | LVFW | Apical | 1 | 0 | 415 | – | + | – |
| 4 | 72 | W | F | 28.2 | 0 | + | 0 | 0 | + | + | 0 | LVFW | P | 6 | 0 | 555 | + | + | 4 |
| 5 ∗ | 78 | W | F | 23.9 | 0 | + | 0 | + | + | + | 0 | LVFW | A | 1 | 0 | 325 | – | + | – |
| 6 | 83 | W | F | 41.3 | 0 | 0 | 0 | 0 | 0 | + | 0 | LVFW | P | 4 | + | 415 | + | + | 5 |
| 7 | 47 | W | M | 28.3 | 0 | 0 | 0 | 0 | 0 | + | 0 | LVFW | A | 45 | 0 | 435 | + | + | 6 |
| 8 | 57 | W | M | 27.2 | 0 | + | + | + | + | 0 | 0 | LVFW | A | 15 | 0 | 640 | + | + | – |
| 9 ∗ | 66 | W | M | 25.8 | 0 | + | 0 | + | 0 | 0 | + | LVFW | A | 2 | 0 | 430 | + | + | – |
| 10 | 67 | W | M | 28.4 | 0 | + | 0 | 0 | 0 | + | 0 | LVFW | A | 3 | 0 | 390 | + | + | 7 |
| 11 | 67 | W | M | 29.4 | + | + | + | 0 | 0 | 0 | 0 | LVFW | P | 3 | 0 | 660 | + | + | 8 |
| 12 | 70 | W | M | 24.3 | + | + | + | 0 | 0 | + | 0 | LVFW | P | 5 | 0 | 395 | + | 0 | – |
| 13 | 70 | W | M | 30.4 | 0 | + | 0 | 0 | 0 | 0 | 0 | LVFW | P | 4 | 0 | 530 | + | + | – |
| 14 | 75 | W | M | 30.1 | 0 | + | 0 | 0 | 0 | + | 0 | LVFW | L | 2 | 0 | 450 | + | + | 9 |
| 15 | 75 | W | M | 25.2 | + | + | + | 0 | 0 | 0 | 0 | LVFW | P | 3 | + | 575 | + | + | – |
| 16 | 78 | W | M | 26.8 | 0 | + | + | 0 | + | 0 | 0 | LVFW | A | 1 | 0 | 415 | + | + | 10 |
| 17 | 81 | W | M | – | 0 | + | – | 0 | 0 | 0 | 0 | VS | A | 1 | 0 | 500 | + | 0 | – |
| 18 | 80 | W | F | 27.4 | 0 | – | – | 0 | 0 | + | 0 | PM ‡ | P | 3 | + | 380 | 0 | 0 | 11 |
| 19 | 62 | W | M | 31.6 | 0 | + | + | + § | 0 | 0 | 0 | PM ‡ | A | 3 | 0 | 570 | + | 0 † | – |
| 20 ∗ | 63 | W | M | 27.1 | 0 | + | + | 0 | 0 | 0 | 0 | PM ‡ | P | 2 | 0 | 740 | + | 0 | – |
| 21 | 72 | W | F | 25.1 | 0 | + | + | 0 | + | 0 | 0 | LVFW & VS | P | 3 | + | 310 | + | + | 12 |
| 22 | 67 | W | M | 26.1 | + | + | 0 | + | 0 | + | 0 | LVFW & VS | P | 7 | + | 480 | + | 0 † | 13 |
| 23 | 67 | W | M | 26.9 | 0 | + | 0 | 0 | 0 | 0 | 0 | LVFW & VS | P | 1 | + | 530 | 0 | + | – |
| 24 | 81 | W | M | 32.3 | 0 | + | 0 | 0 | + | + | 0 | LVFW & VS | P | 4 | + | 565 | 0 | + | 14 |
| 25 | 77 | W | F | 30.2 | 0 | + | 0 | + | 0 | 0 | 0 | LVFW & PM | L | 7 | 0 | 525 | + | + | 15 |
∗ Heart specimen was not examined by WCR, but photographs taken at autopsy were available.
† No hemopericardium due to earlier CABG causing absence of pericardial space (diffuse adherence of parietal and epicardial surface).
| Variable | Rupture | P Value ∗ | |
|---|---|---|---|
| Yes (n=25) | No (n=39) | ||
| Men : Women | 16 (64%) : 9 (36%) | 23 (59%) : 16 (41%) | 0.690 |
| Ages (years) range (mean) | 0.001 | ||
| Men | 47-81 (68) | 33-83 (56) | |
| Women | 68-83 (75) | 42-88 (65) | |
| Black : white | 2 (8%) : 23 (92%) | 10 (28%) : 26 (72%) † | 0.060 |
| Body mass index (kg/m 2 ) | 0.048 | ||
| Men | 15/16 | 12/23 | |
| Range (mean) | 24.3-32.3 (28.0) | 26.0-64.6 (35.3) | |
| Women | 7/9 | 13/16 | |
| Range (mean) | 23.9-41.3 (28.6) | 18.7-49.5 (31.2) | |
| Diabetes mellitus | 0.034 | ||
| Men | 4 (25%) | 6/19 (32%) | |
| Women | 2 (22%) | 12 (75%) | |
| Systemic hypertension (by history) | 0.162 | ||
| Men | 15/16 (94%) | 17/20 (85%) | |
| Women | 6/8 (75%) | 9 (56%) | |
| Coronary bypass | 6 (24%) | 11/35 (31%) | 0.532 |
| Thrombolytic therapy | 8 (32%) | 4 (10%) | 0.031 |
| Percutaneous coronary intervention | 11 (44%) | 17/38 (45%) | 0.954 |
| Left ventricular Scar | 1 (4%) | 11 (28%) | 0.016 |
| Location of AMI | 0.470 | ||
| Posterior | 12 (48%) | 22 (56%) | |
| Anterior | 9 (36%) | 10 (26%) | |
| Lateral | 3 (12%) | 5 (13%) | |
| Circumferential | 0 | 2 (5%) | |
| Apical | 1 (4%) | 0 | |
| Right ventricular Infarct | 7 (28%) | 5 (13%) | 0.132 |
| Heart weight (g) range (mean) | 0.929 | ||
| Men | 390-740 (519) | 375-1060 (565) | |
| Women | 310-555 (412) | 310-660 (402) | |
| Floating Heart | 19/23 (83%) | 6/30 (20%) | <0.001 |
| Hemopericardium | 19 (76%) | 0 | <0.0001 |
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