108 Part IV / Mechanical Complications
In some cases, the patient may have tamponade resulting from pericarditis and not
VFWR. The electrocardiographic findings of pericarditis include persistent or new ST-
segment elevations, persistently positive T-waves, or inverted T-waves becoming positive
(74,115,116). These findings are insensitive and nonspecific, and the ECG cannot be
considered a useful tool for the diagnosis (58,70). However, echocardiography showing
a >5 mm pericardial effusion in a patient with acute MI and transient hypotension,
electromechanical dissociation, or syncope is highly indicative of VFWR (58,114).
Ventricular free wall rupture may be the presenting manifestation of acute MI (117),
especially in diabetic patients (118). In others, the acute MI might be silent or subclini-
cal, and the first episode of chest pain may be related to the cardiac rupture (88).
Diagnosis
Ventricular free wall rupture must be suspected in any patient with shock or chest
pain suggestive of infarct extension or severe arrhythmias followed by shock (74). The
abrupt development of electromechanical dissociation in patients without preceding
heart failure is highly predictive of VFWR (110), but this association is less strong in
patients with preceding heart failure.
ECHOCARDIOGRAPHY
Echocardiography is the most widely used tool for diagnosing VFWR (88,92,119,120),
yet pericardial effusion is often found in patients after acute MI (up to 28%) even without
cardiac rupture (58,121). López-Sendón et al. found pericardial effusion in patients with
and without ruptures and concluded that the absence of pericardial effusion excludes
VFWR, but the presence of effusion does not prove the existence of VFWR (58). In con-
trast, in the SHOCK trial, only 15 of the 20 patients with VFWR who underwent echocar-
diography had pericardial effusion (81).
Echocardiographic signs of increased intrapericardial pressure and tamponade are
frequently seen in patients with acute MI and pericardial effusion associated with
VFWR (58). In addition, high acoustic echoes within the pericardial effusion are
indicative of blood clots in the pericardial cavity and have been described in patients
with subacute VFWR (58,70,88,122–126). However, these high acoustic echoes can
also be found in patients with fibrinous pericarditis who may have acute MI without
VFWR (127). In some patients, pericardial fat can be misdiagnosed as thrombus
because of high acoustic echoes on an echocardiogram. However, compared with fat,
pericardial thrombus has a layered appearance and a higher echodensity (128).
In some cases, direct visualization of the myocardial tear is possible
(63,70,81,88,92,122,129,130). Recent improvements in echocardiographic imaging
allow identification of myocardial tears in a larger percentage of patients with
VFWR. For example, intravenous injections of echocardiographic contrast agents
result in the contrast agent appearing in the pericardial space or pseudoaneurysm
(131). Echocardiography is also useful to identify acquired VSR and acute MR that
may mimic or be associated with VFWR. In patients who have poor transthoracic
echocardiographic images that are often found in those being treated with mechani-
cal ventilation, transesophageal echocardiography may be needed for diagnosing
VFWR and identifying the exact site of the myocardial tear (132,133).
Following echocardiographic documentation of pericardial effusion and tamponade,
pericardiocentesis should be performed emergently to relieve pericardial tamponade
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