Letter to the Editor: Left ventricular free wall rupture: still a complication that negatively affects the in-hospital survival

Abstract

In their multicenter retrospective study, Yoneyama et al. [1] investigated the relation between the onset of acute myocardial infarction (AMI) and the occurrence of cardiac rupture. The primary outcome was the in-hospital mortality. The authors made an interesting and timely analysis of a cohort of 183 patients which were divided into 3 groups according to cardiac rupture time presentation: AMI-to-cardiac rupture time < 24 h, AMI-to-cardiac rupture time ranging between 24 and 48 h and AMI-to-cardiac rupture time > 48 h. Interestingly, the in-hospital death was more represented in patients who experienced cardiac rupture < 24 h after AMI onset and patients who underwent surgery had a more probability to survive compared to patients who did not undergo cardiac repair (44.8% vs 90.6%, respectively; p < 0.001). In this study, left ventricular free wall rupture (LVFWR) was the more represented complications, approaching to around 62% of all patients included. Compared to the ventricular septal defect and papillary muscle rupture, LVFWR is the complication with the highest mortality, especially when this occurred as blowout rupture. In most of the case, patients with blowout rupture had a severe acute cardiogenic shock or even a cardiac arrest at presentation. We have recently reported results of a consecutive series of 35 patients who underwent surgery for repair of LVFWR and we have observed an in-hospital mortality of 34.3%. Also, patients with a blowout type of rupture tended to have a higher in-hospital mortality rate compared to oozing type [2]. Moreover, at multivariate cardiac arrest at presentation was an independent predictor of in-hospital mortality (odds ratio 11.7, 95% confidence interval 2.35–59.06; p = 0.003), confirming the very high probability for patients with blowout type to experience cardiac arrest because of an acute and massive cardiac tamponade. Our results were also consistent with data reported by Okamura et al. [3] and by Matteucci and colleagues [4]. In Yoneyama’s study [1], the type of LVFWR was not mentioned and, although the frequency distribution of free wall rupture is similar among the three groups, it is not possible to make an association between the type of rupture and the AMI-to-cardiac rupture time. In our mind, it is reasonable to allocate the blowout rupture in the AMI-to-cardiac rupture time < 24 h. The lowest frequency of surgical repair among these patients might be due to the highest frequency of blowout rupture in this group. Another issue to consider is the use of mechanical supports at presentation, such as intraaortic balloon pump and extracorporeal life support which are strongly indicated in case of acute cardiogenic shock and cardiac arrest [5] and may positively affect the in-hospital course of these very high-risk patients [4].