Myocardial Rupture in the ER. How common?

[Ceke2002]

Genuinely curious about this. How common is it to see a Myocardial Rupture (presuming the patient even makes it to the ER)? Is it one of those 'once or twice in an entire medical career' kind of things, or would you see at least 1-2 per year, or somewhere in between that? What are the average survival rates of these patients?

My Grandmother died from a Myocardial Rupture in the early 80s ( Left Ventricular Free Wall Rupture post Anterior MI). Death was pretty much instantaneous (I know, because I witnessed it). At the time it was indicated to us that a-) Heart rupture was a very rare complication of MI, and b-) that it had a zero rate of survivability. Have often wondered with advances in medicine over the past 40 or so years if this was still a rare event (better diagnostic tools perhaps) and/or if survivability rate had increased?

Feel free to include examples, like I said I'm just genuinely curious about this.

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[bravotwozero]

Extremely rare, still low survivability unless immediately sent to OR

 

[CoolDoc1729]

Genuinely curious about this. How common is it to see a Myocardial Rupture (presuming the patient even makes it to the ER)? Is it one of those 'once or twice in an entire medical career' kind of things, or would you see at least 1-2 per year, or somewhere in between that? What are the average survival rates of these patients?

My Grandmother died from a Myocardial Rupture in the early 80s ( Left Ventricular Free Wall Rupture post Anterior MI). Death was pretty much instantaneous (I know, because I witnessed it). At the time it was indicated to us that a-) Heart rupture was a very rare complication of MI, and b-) that it had a zero rate of survivability. Have often wondered with advances in medicine over the past 40 or so years if this was still a rare event (better diagnostic tools perhaps) and/or if survivability rate had increased?

Feel free to include examples, like I said I'm just genuinely curious about this.

I think this is maybe a once in a career thing. We also wouldn’t necessarily know it happened, just suddenly the patient would become unstable and die within a couple minutes. I don’t think it’s survivable unless it literally happened IN an operating room, then maybe 25% chance of survival

 

[Ceke2002]

Extremely rare, still low survivability unless immediately sent to OR

Thanks. I guess low survivability is still an improvement on zero survivability.

 

[Ceke2002]

I think this is maybe a once in a career thing. We also wouldn’t necessarily know it happened, just suddenly the patient would become unstable and die within a couple minutes. I don’t think it’s survivable unless it literally happened IN an operating room, then maybe 25% chance of survival

The bolded part is definitely in line with my experience. From onset of symptoms to sudden death was no more than a minute or so. We didn't even have a chance to call an ambulance before she died. Interesting that operating room survival rate is maybe 25%, in 1981 it was more like, 'this could've literally happened in the most well equipped hospital in the world, surrounded by the best medical specialists and surgeons available, and it would still be a non survivable event'.

 

[gutonc]

The bolded part is definitely in line with my experience. From onset of symptoms to sudden death was no more than a minute or so. We didn't even have a chance to call an ambulance before she died. Interesting that operating room survival rate is maybe 25%, in 1981 it was more like, 'this could've literally happened in the most well equipped hospital in the world, surrounded by the best medical specialists and surgeons available, and it would still be a non survivable event'.

I think you're missing the point.

IF this happened in the OR, AND the patient's chest was already cracked, AND they were already on heart-lung bypass, AND the CT surgeon had a scalpel in hand, THEN AND ONLY THEN is there a very low, but non-zero, chance of surviving this.

 

[Ceke2002]

I think you're missing the point.

IF this happened in the OR, AND the patient's chest was already cracked, AND they were already on heart-lung bypass, AND the CT surgeon had a scalpel in hand, THEN AND ONLY THEN is there a very low, but non-zero, chance of surviving this.

Ah, okay, I get it now. Thanks. I was thinking 'OR on immediate standby, patient already in hospital'. What you said makes more sense.

 

[Tenk]

You will probably never know that you see this. You may hear about it later if they perform an autopsy.

 

[HemeOncHopeful19]

Google said this OP

"In patients with acute myocardial infarction, left ventricular free wall rupture is an infrequent complication (2–4%) but it is associated with a high mortality from pericardial tamponade.1-8 It accounts for 5–24% of all in hospital deaths related to acute myocardial infarction."

Reading this thread and how terrible the outcomes are/helpless we are to fix it I am a little annoyed about all of the times over the years I have had to diagnose this on a test question when apparently I was never going to help the patient anyway with my diagnosis.

 

[Apollyon]

The stat I recall from almost 30 years ago is 2% or less, but, that means, to EMS, all CPR and ACLS prehospital will be unsuccessful, for, at that moment, unknown reasons.

It brings to mind the old joke: "Internal medicine knows everything, and does nothing. Surgeons know nothing, and do everything. Psychiatrists know nothing and do nothing. Pathologists know everything and do everything, but they're always 2 days too late!"

 

[lucid_leprechaun]

I imagine it’s like doing a thoracotomy and finding a severe posterior heart injury. They bleed out almost immediately so unless you are working on ECMO, plugging the hole, and pouring blood into them there’s no survival. Takes a unique shop with lots of specialists

 

[Dr Mantis Toboggan]

I imagine it’s like doing a thoracotomy and finding a severe posterior heart injury. They bleed out almost immediately so unless you are working on ECMO, plugging the hole, and pouring blood into them there’s no survival. Takes a unique shop with lots of specialists

Our hospital had a patient who had a contained rupture and survived transfer to bypass center 30 min away. The CT surgeon sent a cell phone video of the chest open. Wild case.

 

[BoardingDoc]

Our hospital had a patient who had a contained rupture and survived transfer to bypass center 30 min away. The CT surgeon sent a cell phone video of the chest open. Wild case.

Yeah, there are case reports about people with preexisting pericardial scarring which allowed the free wall rupture to be contained long enough to make it to the OR.

Suffice it to say, survival for this condition is essentially zero barring an extremely unlikely confluence of events.

 

[southerndoc]

Saw one a few months ago. Guy having chest pain for several days, went to urgent care, referred to ER. He drove himself and coded in triage immediately after they got a 12-lead. Gave him alteplase but never got him back. ME said he had a wall rupture from an MI. If only he had presented to us earlier.

 

[The Knife & Gun Club]

Early in my career but I’ve yet to see a free wall rupture from MI (that I knew of). I’ve had one free wall rupture with tamponade from outpatient AICD placement and the patient survived to OR, cannulated onto ecmo, and ultimately walked out - but that case they still had the wire suck through their myocardium when they showed up in the ED and I’m guessing they had a very small, wire sized defect.

I’d imagine the incidence of free wall rupture from MI is a bit higher in retrospect since we don’t always know in the ED and it’s diagnosed on autopsy.

Only other cardiac tamponade from atraumatic hemoparicardium I’ve encountered so far was due to a dissection, which has similar physiology I guess. That dude did not make it despite a very aggressive full court press including a needle in the chest, ACLS, fluids, etc.

Without the ability to immediately crash the person onto VA ECMO during cardiac arrest in the resus room I don’t think that is a survivable injury - and I can count the number of hospitals in the US with that capacity on one hand.

 

[Beeftenderloin]

Anesthesiologist here.

Have seen a low single digit number of contained ruptures come to the OR. Usually patients with prior sternotomy/pericardial scarring that keeps the new post-MI rupture from filling the whole pericardium (which would otherwise lead to tamponade and near immediate death).

True LV free-wall rupture with a “normal” pericardium will be fatal 100% of the time unless the groins are already wired, bypass circuit is primed and surgeons got a saw in their hand.

Had an RV free wall rupture come to OR couple months ago. Post CV surgery patient, midlevel pulled out temp pacing wire (they’re supposed to be sewn in so they can be easily/atraumatically pulled out post-op, this one wasn’t). Acute tamponade in ICU. Ended up coding and getting their chest cracked in the unit with only a 20g for access. Drained the blood, put a finger on the hole and rushed down hall to OR with open chest. Patient lived.

 

[pollyspockets]

Probably more common, but just recently had two cases of septal rupture after delayed presentation of MI. One made it to surgery and walked out, surgery not offered to second due to unstable cardiogenic shock and was palliated

 

[Clean7795]

Our hospital had a patient who had a contained rupture and survived transfer to bypass center 30 min away. The CT surgeon sent a cell phone video of the chest open. Wild case.

I have seen a similar case where a patient had a contained rupture/pseudoaneurysm.

Probably a similar idea to traumatic aortic dissections, where aortic root dissections/ruptures die in the field so the only ones that make it to the hospital are the ones that haven't caused major vascular occlusion/rupture.

 

[The Knife & Gun Club]

I have seen a similar case where a patient had a contained rupture/pseudoaneurysm.

Probably a similar idea to traumatic aortic dissections, where aortic root dissections/ruptures die in the field so the only ones that make it to the hospital are the ones that haven't caused major vascular occlusion/rupture.

How often do y’all see the traumatic dissections out in the community? They seem decently common at my trauma center but it’s a big academic place that I’ve heard sees a lot.

We get ~5-6/month, it’s so common the surgeons have a custom order set and the Gen surg residents seem to love doing them.

 

[BoardingDoc]

How often do y’all see the traumatic dissections out in the community? They seem decently common at my trauma center but it’s a big academic place that I’ve heard sees a lot.

We get ~5-6/month, it’s so common the surgeons have a custom order set and the Gen surg residents seem to love doing them.

I don't work at a trauma center. I am aware of literally 0 having ever presented to my hospital while I've worked there.

Did residency at a lvl 1 trauma center. I did not personally treat any traumatic dissections that I can recall. It's possible that I'm the outlier. I think it's your hospital though. Seriously, it sounds like your hospital caters solely to members of the school of aggressive driving and connective tissue disorders.

 

[Clean7795]

Traumatic dissection involving any major artery? Not infrequently (most common being vertebral, then carotids, then iliacs). Involving the aorta? Once. Having 5-6 traumatic aortic dissections per month would be unusually common.

 

[thegenius]

How often do y’all see the traumatic dissections out in the community? They seem decently common at my trauma center but it’s a big academic place that I’ve heard sees a lot.

We get ~5-6/month, it’s so common the surgeons have a custom order set and the Gen surg residents seem to love doing them.

Almost never that we can diagnose....

 

[Janders]

Yeah I haven’t seen or heard of a case being discovered in the last 350,000 patients at our community hospital (non-trauma).

We get a couple of blunt trauma died a block from us stat EMS drop offs a year, and I suppose some of those may have died of aortic rupture or dissection, but they dead and unless its found on post…

How often do y’all see the traumatic dissections out in the community? They seem decently common at my trauma center but it’s a big academic place that I’ve heard sees a lot.

We get ~5-6/month, it’s so common the surgeons have a custom order set and the Gen surg residents seem to love doing them.

 

[CoolDoc1729]

I don't work at a trauma center. I am aware of literally 0 having ever presented to my hospital while I've worked there.

Did residency at a lvl 1 trauma center. I did not personally treat any traumatic dissections that I can recall. It's possible that I'm the outlier. I think it's your hospital though. Seriously, it sounds like your hospital caters solely to members of the school of aggressive driving and connective tissue disorders.

Marfan Memorial, right?

 

[The Knife & Gun Club]

Glad to know it is unusual. Miami + being the major trauma center right off I-95 produces a wild volume of really really fast really really bad/drunk drivers.

I still remember one dude I had as an intern who wrecked his slingshot (those 3 wheeled motorcycle things) going close to 150 mph. He went to the OR for a stat TEVAR and lived which was neat. Then a full year later when I was rotating in ICU he got admitted to me again as a rapid from the floor for sepsis. The dude had been admitted for an entire year, basically a trached pegged Neuro catastrophe who couldn’t keep from aspirating long enough to make it to an LTACH. Super sad. He had this “tiger claw” scar across his chest from where he rode a piece of glass across the Highway that was super memorable.

 

[Ceke2002]

Saw one a few months ago. Guy having chest pain for several days, went to urgent care, referred to ER. He drove himself and coded in triage immediately after they got a 12-lead. Gave him alteplase but never got him back. ME said he had a wall rupture from an MI. If only he had presented to us earlier.

That sounds very similar to what happened with my Grandma (although she never made it to urgent care). About 3-4 months before the event she had had a couple of nasty falls, and was experiencing episodes of brief LOC 2-3 times a week. Like most people of her vintage back then she adamantly refused to go to the Doctor and insisted she could take care of herself and there was nothing to worry about, my Mum had different ideas and essentially forced her to book a cardiology appointment.

At the time of her death she was undergoing a series of tests, but again this was all very much played down by her as 'no big deal'. A week before her death she was complaining a bit of 'heart burn' and 'indigestion', taking Mylanta, and telling everyone to stop worrying. Then we'd just finished tea one night, Grandma went to her room, Mum and I got up to start clearing the table & getting ready to do the dishes, Grandma called out for my Mum, we both rushed into her room, she was clutching her chest and obviously in a lot of pain, Mum sat on the bed next to her and asked her what was wrong, she had just enough time to tell my Mum not to panic and then fell back dead.

Of course in hindsight we understood that the 'indigestion' and 'heart burn' she was experiencing a week prior was more likely cardiac chest pains that she was ignoring. I was present when the autopsy results were discussed (home visit, I just happened to be in the room) & in layman's terms it was explained as 'She had a massive heart attack, and the left wall of her heart blew out' (which my Mum wrongly interpreted as meaning her entire heart had literally exploded in her chest).

 

[Ceke2002]

Reading this thread and how terrible the outcomes are/helpless we are to fix it I am a little annoyed about all of the times over the years I have had to diagnose this on a test question when apparently I was never going to help the patient anyway with my diagnosis.

You might not be able to help the patient, but diagnosing, understanding the diagnosis, and being able to convey that information to the average layperson can go a long way towards helping the patient's family and/or loved ones.

 

[greatnt249]

You might not be able to help the patient, but diagnosing, understanding the diagnosis, and being able to convey that information to the average layperson can go a long way towards helping the patient's family and/or loved ones.

You're likely not going to be able to have a diagnosis until after autopsy, and even then family will walk away with the message that the patient's heart "exploded."

 

[Apollyon]

You're likely not going to be able to have a diagnosis until after autopsy, and even then family will walk away with the message that the patient's heart "exploded."

No, affirmatively. The only other way you would confirm myocardial rupture would be cracking the chest in the ED.

Well, maybe you could, by chance, see it on US.

 

[Ceke2002]

You're likely not going to be able to have a diagnosis until after autopsy, and even then family will walk away with the message that the patient's heart "exploded."

That is a very good point re conclusive diagnosis after autopsy. And of course I would assume there will always be some patients that will hear what they wish to hear, or completely misinterpret what they were told. All of the medical professionals who assisted us that night, and in the following days, were wonderful and helped the majority of my family a great deal. I have always been very grateful to them, and wished to convey that to other Doctors.