Download Cardiac Rupture Complicating Acute Myocardial Infarction in the

Cardiac Rupture Complicating Acute
Myocardial Infarction in the Direct
Percutaneous Coronary Intervention
Reperfusion Era*
Hon-Kan Yip, MD; Chiung-Jen Wu, MD; Hsueh-Wen Chang, PhD;
Chao-Ping Wang, MD; Cheng-I Cheng, MD; Sarah Chua, MD, FCCP; and
Mien-Cheng Chen, MD
Background: Cardiac rupture, an uncommon yet catastrophic complication after acute myocardial
infarction (AMI), has been studied primarily in the prethrombolytic and thrombolytic therapy eras
but not in the direct percutaneous coronary intervention (d-PCI) reperfusion therapy era. The aim of
this study was to delineate the incidence, potential risks, timing of occurrence, clinical features, and
outcomes of cardiac rupture complicating AMI after d-PCI.
Methods and results: Between May 1993 and July 2002, a total of 1,250 patients with AMI underwent
d-PCI in our hospital. Of these 1,250 patients studied, 12 patients (0.96%) had cardiac rupture
(ventricular septal defect [VSD], three patients; left ventricular [LV] free wall rupture, nine patients]
after d-PCI, with a mean (ⴞ SD) time of occurrence of 52.3 ⴞ 36.2 h. Three patients with VSD had
an insidious presentation, and two of these patients (66.6%) survived after surgical intervention.
However, nine patients with LV free wall rupture always presented with sudden and unanticipated
hemodynamic collapse. Cardiopulmonary resuscitation was uniformly unsuccessful in patients with
LV free wall rupture, and all patients died as a result of this complication within minutes of its onset.
The 30-day mortality rate was significantly higher in patients with cardiac rupture than in patients
without this complication (83.3% vs 8.2%, respectively; p < 0.001). Univariate analysis demonstrated
that the left anterior descending artery was the most likely to be totally occluded in patients who had
developed cardiac rupture (100% vs 66.4%, respectively; p ⴝ 0.033). Multiple stepwise logistic
regression analysis demonstrated that the most significant factors associated with cardiac rupture
were advanced age, female gender, and lower body mass index (BMI; all p < 0.05), whereas early
reperfusion with d-PCI was an independent determinant of preventing this complication
(p < 0.0001).
Conclusion: Compared with the prethrombolytic era, our study showed that d-PCI had a favorable
impact on reducing the incidence of cardiac rupture after AMI. Old age, female gender, lower BMI,
and longer time to reperfusion carried a substantially increased risk of cardiac rupture after patients
experienced AMIs. Early successful d-PCI was the most powerful determinant of the avoidance of this
catastrophic complication after AMI.
(CHEST 2003; 124:565–571)
Key words: acute myocardial infarction; cardiac rupture; direct percutaneous coronary intervention
Abbreviations: AMI ⫽ acute myocardial infarction; BMI ⫽ body mass index; d-PCI ⫽ direct percutaneous coronary
intervention; IRA ⫽ infarct-related artery; LV ⫽ left ventricle ventricular; TIMI ⫽ Thrombolysis in Myocardial Infarction;
VSD ⫽ ventricular septal defect
upture of the myocardium after acute myocarR dial
infarction (AMI) may involve the free wall of
the left ventricle (LV), the interventricular septum,
or the papillary muscles.1–3 While LV free wall
rupture and ventricular septal defect (VSD) are
uncommon mechanical complications after AMI,
*From the Division of Cardiology (Drs. Yip, Wu, Wang, Cheng,
Chua, and Chen), Chang Gung Memorial Hospital, Kaohsiung,
Taiwan, Republic of China; and the Department of Biological
Sciences (Dr. Chang), National Sun Yat-Sen University, Kaohsiung, Taiwan, Republic of China
Manuscript received August 27, 2002; revision accepted December 12, 2002.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail:
[email protected]).
Correspondence to: Mien-Cheng Chen, MD, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial
Hospital, Kaohsiung 123, Ta Pei Rd, Niao Sung Hsiang, Kaohsiung Hsien, 83301, Taiwan, Republic of China; e-mail: chenmien@
kinghenry.com.tw
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565
they carry an extremely high mortality rate.1– 4 The
incidence,2,4 – 6 timing of occurrence,7,8 prognostic factors,2 and clinical features9,10 and outcomes1– 4,11,12 of
AMI complicated by VSD and LV free wall rupture in
both the prethrombolytic and thrombolytic therapy
eras have been debated extensive. However, there are
no available data with regard to the incidence, clinical
features, and outcomes of these complications in patients with AMI undergoing direct percutaneous coronary intervention (d-PCI). Furthermore, previous studies11,12 have demonstrated that although thrombolytic
therapy can reduce the incidence of cardiac rupture,
this therapeutic management for patients with AMI
also may accelerate early cardiac rupture.2,12 Whether
this paradoxical effect of thrombolytic therapy also
occurs in the present d-PCI reperfusion era remains
unknown. Therefore, the aim of this study was to
investigate the incidence, associated potential risk factors, timing of occurrence, and clinical outcomes of this
complication in patients with AMI who have receiving
d-PCI therapy, and the impact of d-PCI on and the
importance of reperfusion time in this complication.
Materials and Methods
Patient Population
In our hospital, there were only a small number of patients
with AMI who either refused d-PCI or were treated with lytic
therapy. Most of the patients with AMI underwent d-PCI after
informed consent was obtained. For the purpose of the study, all
patients who underwent d-PCI were prospectively identified and
entered into a computerized database. Between May 1993 and
July 2002, d-PCI was performed in 1,250 patients of any age who
had presented with AMI of ⬍ 12 h duration (or had experienced
cardiogenic shock within 18 h) in our hospital. Of these 1,250
patients, 12 (0.96%) had cardiac rupture (including 3 patients
with VSD and 9 patients with LV free wall rapture) that had
occurred after receiving d-PCI. These 12 patients constituted our
study population (group 1). The remaining 1,238 patients served
as the control group (group 2).
Procedure and Protocol
The procedure and protocol have been described previously in
detail.13,14 Before stents were available in our country, primary
balloon angioplasty was performed in these patients, however,
after stents were available in our country, stent implantation was
strongly encouraged unless the infarct-related artery (IRA) had
heavy calcification, a reference lumen diameter of ⬍ 2.5 mm, or
a stent-like formation on the treatment site after coronary
angioplasty. Left ventriculograms, which were immediately performed after angioplasty, were recorded for 30° right anterior
oblique and 60° left anterior oblique views. Echocardiography
was routinely performed in each patient either before or after
d-PCI.
Platelet glycoprotein IIb/IIIa receptor antagonists have been
available in our country since August 2000. In our hospital, all
patients with AMIs are considered eligible for therapy with
glycoprotein IIb/IIIa on presentation in the emergency depart-
ment after informed consent is obtained, unless there are
contraindications. As a result of our government medical insurance policy, only 8 patients (including 1 patient with LV free
wall rupture) received abciximab therapy (a loading dose of
0.25 mg/kg body weight, followed by a maintenance infusion of
0.1 mg/min for 18 to 24 h), and 300 patients (including 2 patients
with LV free wall rupture) received tirofiban therapy (a loading
dose of 20 ␮g/kg body weight, followed by a maintenance
infusion of 0.15 ␮g/min for 18 to 24 h). Continuous heparin
infusion for a further 24 to 48 h was administered only to patients
who received balloon angioplasty. Patients were treated with
ticlopidine for 2 weeks if stenting was performed. Aspirin
(100 mg po once a day) was administered to each patient
indefinitely. All other medications, including nitrates, beta-blockers, diuretics, and angiotensin-converting enzyme inhibitors were
used as needed in both groups.
Definitions
AMI was defined as the following: (1) typical chest pain
lasting for ⬎ 30 min with ST-segment elevation of ⬎ 1 mm in
two consecutive precordial or inferior leads and (2) typical
chest pain lasting for ⬎ 30 min with a new onset of complete
left bundle branch block. Procedural success was defined as a
reduction in residual stenosis of ⬍ 50% by balloon angioplasty
or successful stent deployment at the desired position with a
residual stenosis of ⬍ 20% followed by Thrombolysis in
Myocardial Infarction (TIMI)15 grade 3 flow in the IRA. Body
mass index (BMI) was defined as the weight (in kilograms)
divided by the square of the height (in meters). VSD was first
suspected by physical examination and subsequently was
confirmed by echocardiography, a significant step-up in oxygen saturation between the right atrium and the pulmonary
artery using a Swan-Ganz catheter, and operative findings. LV
free wall rupture was suspected by a patient’s sudden hemodynamic collapse associated with the patient’s loss of consciousness and electromechanical dissociation without ECG
evidence of malignant ventricular tachyarrhythmias. A diagnosis subsequently was made by echocardiographic findings of a
new accumulated pericardial effusion and further was confirmed by pericardiocentesis via an apical approach method.
Data Collection
Detailed in-hospital and follow-up data including age, sex,
coronary risk factors, Killip score on hospital admission, reperfusion time, pre-TIMI and post-TIMI flow grades, angiographic
results, number of diseased vessels and coronary aneurysms, and
number of in-hospital adverse events were obtained. These data
were collected prospectively and were entered into a computerized database.
Statistical Analysis
Data were expressed as the mean ⫾ SD. Continuous variables
were compared using the Wilcoxon rank sum test. Categoric
variables were compared using the ␹2 test or Fischer exact test.
Stepwise logistic regression analysis was used to determine the
independent determinants of cardiac ruptures after d-PCI. Statistical analysis was performed using a statistical software package
(SAS for Windows, version 6.12; SAS Institute; Cary, NC). A
probability value of ⬍ 0.05 was considered to be statistically
significant.
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Clinical Investigations
Results
Baseline Clinical Characteristics of the Patients
Relevant patient baseline characteristics are summarized in Tables 1. There were no significant
differences in terms of the presence of diabetes
mellitus or hypercholesterolemia, previous myocardial infarction, infarction locations, and the incidences of cardiogenic or noncardiogenic shock between patients with cardiac rupture and those
without. However, patients with cardiac rupture had
significantly higher incidences of hypertension and
current smoking than did patients without this complication. Furthermore, patients with cardiac rupture were significantly older and thinner than were
patients without this complication. By univariate
logistic regression analysis, old age was significantly
related to increased incidence of cardiac rupture
(odds ratio, 1.11; 95% confidence interval, 1.04 to
1.18; p ⫽ 0.0007). Moreover, the incidence of female gender was significantly higher in patients with
cardiac rupture than in patients without it. In this
study, female patients were significantly older than
male patients (67.1 ⫾ 11.7 vs 60.8 ⫾ 11.9, respectively; p ⫽ 0.0001). In addition, in the 12 patients
with cardiac rupture, female patients were also older
than male patients, although the difference did not
reach statistical significance as a result of a type-2
error (75.1 ⫾ 7.7 vs 70.5 ⫾ 3.5, respectively;
p ⫽ 0.286).
Table 1—Baseline Characteristics Between Patients
With and Without Cardiac Rupture*
Variables
Age, yr
Female sex
Hypertension
Smoking
Diabetes mellitus
Hypercholesterolemia
Previous MI
BMI
Preinfarction angina
Infarction location by ECG
Anterior
Inferior
Lateral
Non-Q wave
Killip classification
Cardiogenic shock
Noncardiogenic shock
Cardiac
Rupture
(n ⫽ 12)
Noncardiac
Rupture
(n ⫽ 1,238)
73.6 ⫾ 6.8
66.7 (8/12)
83.3 (10)
25 (3)
25 (3)
41.7 (5)
0 (0)
22.3 ⫾ 4.1
16.7 (2)
61.7 ⫾ 11.9
15.7 (194)
49.0 (607)
55.7 (690)
25.2 (312)
43.4 (537)
11.1 (138)
25.5 ⫾ 4.1
31.7 (393)
83.3 (10)
16.7 (2)
0 (0)
0 (0)
56.9 (705)
39.4 (488)
1.9 (23)
1.8 (22)
16.7 (2)
83.3 (10)
12.7 (157)
87.3 (1081)
p Value
0.0001
⬍ 0.0001
0.018
0.033
1.000
0.905
0.382
0.006
0.359
0.406
0.657
*Values given as mean ⫾ SD or % (No. of patients), unless otherwise
indicated. MI ⫽ myocardial infarction.
Timing of Occurrence, Clinical Presentation, and
Outcomes of Cardiac Rupture
Twelve of the 1,250 patients (0.96%) had cardiac
rupture, including 3 with VSD and 9 with LV free
wall rupture. However, neither pseudoaneurysm nor
incomplete rupture of the LV free wall was found in
these patients. Cardiac rupture developed after dPCI in a mean time of 52.3 ⫾ 36.2 h (range, 4.8 h to
5 days). Clinical symptoms and signs in patients with
VSD mostly showed an insidious presentation, and
progressive dyspnea, worsening congestive heart failure, and pansystolic heart murmur during physical
examination were the usual initial presentations. In
contrast, patients with LV free wall rupture always
presented with precipitous and unanticipated hemodynamic collapse. ECG monitoring showed sinus
tachycardia, sinus bradycardia, junctional escape
rhythm, or standstill without evidence of ventricular
tachycardia/fibrillation. Echocardiograms showed
pericardial effusion (Fig 1). Pericardiocentesis was
performed in five patients and showed clotted blood
in all five. Cardiopulmonary resuscitation was uniformly unsuccessful in patients with LV free wall
rupture, and all patients died as a result of this
complication within minutes after its onset. An operation was performed in the three patients who had
acquired VSD. One patient died in the hospital due
to multiorgan failure, and the other two patients
were discharged from the hospital uneventfully and
have survived to the present.
Angiographic Findings, Angioplasty Results,
Reperfusion Time, and 30-Day Mortality Rate
of Patients
Relevant angiographic results, the time to reperfusion, and clinical outcome are summarized in
Table 2. There were no significant differences in
terms of IRA, number of vessels affected by the
disease, intercoronary collaterals, pre-TIMI and
post-TIMI flow grades, or methods of reperfusion
between patients with and without cardiac rupture.
However, the incidence of a totally occluded left
anterior descending artery (Fig 2) was significantly
higher in patients with cardiac rupture than in patients
without it (100% [9 of 9 patients] vs 66.4% [463 of 697
patients]; p ⫽ 0.033). Furthermore, the mean time to
reperfusion was significantly longer, and the mortality
rate was significantly higher in patients with cardiac
rupture than in patients without it.
Independent Predictors of Cardiac Rupture
Independent determinants of cardiac rupture are
summarized in Table 3. Multiple stepwise logistic
regression analysis demonstrated that only old age,
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567
Figure 1. Left, A: echocardiography (M-mode) was performed after primary stenting, and there was
no pericardial effusion. Middle, B (apical four-chamber view), and Right, C (M-mode): 3 days later,
after primary stenting, sudden hemodynamic collapse occurred in the patient. Echocardiography was
performed, and the result demonstrated that there had been new accumulated pericardial effusion
(black arrows).
female gender, a lower BMI, and a longer time to
reperfusion were significant independent predictors of
cardiac rupture.
Discussion
Incidence of Cardiac Rupture in the d-PCI
Reperfusion Era
In the present study, we found that the overall
incidence of cardiac rupture was 0.96%, including
Table 2—Angiographic Features, Angioplasty Results,
and Mortality in Patients With and Without
Cardiac Rupture*
Variables
Cardiac
Rupture
(n ⫽ 12)
Noncardiac
Rupture
(n ⫽ 1,238)
0.24% for VSD and 0.72% for LV free wall rupture.
To the best of our knowledge, this is the first study to
investigate the incidence, timing of occurrence, clinical features, and outcomes, as well as the predictors
of myocardial rupture in patients with AMI undergoing d-PCI. The incidence of cardiac rupture was
previously reported to be 4% in the prethrombolytic
therapy era5,6 and ⬍ 1.0% in the thrombolytic therapy era.2,12 In addition, the incidence of LV free wall
rupture was reported to be 8 to 10 times more
frequent than that of VSD and the rupture of the
papillary muscle.16 Our findings are consistent with
those of previous thrombolytic reperfusion studies2,7,12 and further confirm the concept that early
successful reperfusion either by thrombolysis or
d-PCI may reduce the incidence of cardiac rupture
after AMI.
p Value
IRA
0.645
LAD
83.3 (10)
56.3 (697)
LCX
0 (0)
7.3 (90)
RCA
16.7 (2)
34.5 (427)
LM
0 (0)
1.9 (24)
Multivessel disease
58.0 (7)
57.0 (706)
0.928
(ⱖ 2 vessels)
Present intercoronary
8.3 (1)
31.4 (389)
0.0705
collaterals
Pre-TIMI flow
0.070
TIMI-0 flow
91.7 (11)
65.9 (816)
ⱖ TIMI-1 flow
8.3 (1)
34.1 (422)
Post-TIMI flow
0.661
TIMI-3 flow
83.3 (10)
84.8 (1,050)
TIMI-2 flow
16.7 (2)
10.3 (127)
ⱕ TIMI-1 flow
0 (0)
4.9 (61)
Method of reperfusion
0.421
Balloon
58.3 (7)
46.7 (578)
Stent
41.7 (5)
53.3 (660)
Mean time to
553.9 ⫾ 201.4 283.2 ⫾ 153.9
0.0007
reperfusion, min
Mortality rate
83.3 (10)
8.2 (102)
⬍ 0.0001
*Values given as mean ⫾ SD or % No. of patients. LAD ⫽ left
anterior descending; LCX ⫽ left circumflex; LM ⫽ left main;
RCA ⫽ right coronary artery.
Timing and Possible Mechanisms of Cardiac
Rupture in the d-PCI Reperfusion Era
It has been stated7,8 that the peak incidence of
cardiac rupture occurs 5 to 7 days after infarction in
the prethrombolytic therapy era. To the contrary,
most cardiac ruptures that are associated with early
thrombolytic therapy occur within 24 h after treatment.2,12,16 These large clinical trials2,12,16 also have
demonstrated that although the frequency of cardiac
rupture decreases, early thrombolytic therapy (ie,
within 6 h) paradoxically accelerates the timing of
this complication, and late thrombolytic therapy has
been found to increase the risk of cardiac rupture.11
Several possible mechanisms, including extension of
myocardial hemorrhage weakening and dissection of
the necrotizing zone,12,16 diminishing of the myocardial collagen content,17 and digestion of collagen by
collagenases18,19 and plasmin,20 have been suggested.
In the present study, several important observations were made. First, the timing of cardiac rupture
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Clinical Investigations
Figure 2. Left, A: right coronary angiogram showed chronic total occlusion of the proximal right
coronary artery (black arrow head) without intercoronary collaterals to the left anterior descending
artery. Middle, B: left coronary angiogram showed total occlusion of the proximal left anterior
descending artery (bigger black arrow head) and moderate atherosclerosis of proximal big obtuse
marginal branch (smaller black arrow head). Right, C: successful stent implantation in the proximal left
anterior descending artery (black arrow heads) with normal coronary blood flow.
in our patients varied (range, 4.8 h to 5 days) with a
mean time of 52.3 h. The mean time of occurrence
of this complication in our patients was earlier than
that in the prethrombolytic therapy era7,8 but was
later than that in the thrombolytic therapy era,2,16
which suggests that reperfusion therapy by d-PCI
does not accelerate the timing of cardiac rupture, as
occurred with thrombolytic therapy.2,12,16 Second,
our patients with cardiac rupture had significantly
longer time to reperfusion than did those without
cardiac rupture. This finding suggests that the risk of
cardiac rupture after AMI is related directly to the
timing of reperfusion. Third, angiographic findings
demonstrated that the incidence of a totally occluded
left anterior descending artery was significantly
higher in patients with cardiac rupture than in
patients without it. This finding suggests that a
transmural myocardial infarction is more likely to
occur in these patients.
Relationships Among Age, Gender, BMI, and
Cardiac Rupture
Advanced age has been found to be an increased
risk factor for adverse outcomes after AMI.21 The
risks increased proportionally with advancing age,
Table 3—Multiple Stepwise Logistic Regression
Analysis of Independent Predictors of
Cardiac Rupture*
Variables
OR
95% CI
p Value
Age
Female sex
BMI
Reperfusion time
1.085
4.854
1.264
0.994
1.008–1.168
1.307–17.857
1.036–1.542
0.992–0.997
0.0272
0.0001
0.0095
0.0001
*OR ⫽ odds ratio; CI ⫽ confidence interval.
and primary angioplasty did not alter the relationship
between adverse outcomes after AMI and being
aged.21 The contributing factors to this relationship
included the presence of additional comorbid conditions, more advanced multivessel disease, and a
longer time between the onset of symptoms and
presentation for evaluation and treatment.21–23 In
the present study, old age was an independent
predictor of cardiac rupture. Our finding confirmed
the strong relationship between advanced age and
increased adverse outcomes in the clinical setting
of AMI.
Morbidity and mortality after AMI have been
reported to be higher in women than in men.24 In
the present study, we also found that female gender
was another independent predictor of cardiac rupture. In the present study, it is interesting to note
that women constituted only 16.2% of our patient
population. However, it is surprising that ⬎ 66% of
patients with cardiac rupture were women. We
remain uncertain why women are more likely to
experience cardiac rupture after AMI. However, this
may be due to older age in female patients and to
other fundamental differences in the biology and
pathophysiology of AMI between men and women.24
In patients with coronary artery disease who are
undergoing PCI, lean patients recently have been
reported25 to be at increased risk for in-hospital
complications and cardiac death. However, the
mechanism by which lean patients have an excess
risk for these complications remains unclear.25 In the
present study, we also found that patients with
cardiac rupture had significantly lower BMI values
than those without this complication. Furthermore,
multiple stepwise logistic regression analysis demonstrated that BMI was an independent predictor of
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CHEST / 124 / 2 / AUGUST, 2003
569
cardiac rupture. This may reflex a synergic effect of
being female and lean body weight on the predilection of cardiac rupture after AMI.
Formidable Challenges for Management of Cardiac
Rupture
It is estimated that 8 to 17% of all fatal myocardial
infarctions are the result of myocardial rupture.26
Despite improvements in medical therapy and in
percutaneous and surgical techniques, mortality
from this complication remains extremely high.2
These patients usually die immediately, even before
a diagnosis can be confirmed.4 In the present study,
we found that the mortality rate caused by cardiac
rupture was 8.9% (10 of 112 patients) of all fatal
myocardial infarctions in our patient population. Our
finding is consistent with previous observations.12,26
The overall mortality rate was very high (83.3%) in
patients with cardiac rupture. It was disappointing
that all of our patients with LV free wall rupture died
despite heroic therapeutic bedside management.
The primary obstacle in preventing death from LV
free wall rupture is the extremely limited time in
which surgery can be initiated, as the occurrence of
LV free wall rupture is sudden and unanticipated
without a constellation of signs or symptoms to
indicate impending rupture in these patients, and it
is followed by rapid hemodynamic deterioration.
There are several limitations to this study. First,
the number of patients with cardiac rupture in this
study was small, therefore, our results should be
viewed as preliminary and need to await confirmation by larger clinical trials. Second, cardiac rupture,
pseudoaneurysm, or incomplete rupture could easily
be missed since premortem echocardiograms were
often unavailable and cultural factors prevent postmortem examination. Therefore, the incidences of
these complications could have been underestimated
in our study. Third, as the number of patients with
cardiac rupture was small in this study, the lack of
significant differences in the incidences of previous
myocardial infarction, anterior wall infarction, preinfarction angina, presence of collateral circulation,
pre-TIMI flow, and method of reperfusion between
patients with cardiac rupture and without could have
been due to a type-2 error.
In conclusion, advanced age, female gender, a
lower BMI, and longer time to reperfusion were
significant independent predictors of cardiac rupture
after AMI, and d-PCI had a favorable impact on
reducing the incidence of cardiac rupture. Early
successful d-PCI was the most significant independent determinant for preventing this catastrophic
complication after AMI.
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