Echocardiographic features of myocardial rupture after acute myocardial infarction on emergency echocardiography

Abstract

Objective: Myocardial rupture is a fatal complication of acute myocardial infarction (AMI). Early diagnosis of myocardial rupture is feasible when emergency physicians (EPs) perform emergency transthoracic echocardiography (TTE). The purpose of this study was to report the echocardiographic features of myocardial rupture on emergency TTE performed by EPs in the emergency department (ED).

Methods: This was a retrospective and observational study involving consecutive adult patients presenting with AMI who underwent TTE performed by EPs in the ED of a single academic medical center from March 2008 to December 2019.

Results: Fifteen patients with myocardial rupture, including eight (53.3%) with free wall rupture (FWR), five (33.3%) with ventricular septal rupture (VSR), and two (13.3%) with FWR and VSR, were identified. Fourteen of the 15 patients (93.3%) were diagnosed on TTE performed by EPs. Diagnostic echocardiographic features were found in 100% of the patients with myocardial rupture, including pericardial effusion for FWR and a visible shunt on the interventricular septum for VSR. Additional echocardiographic features indicating myocardial rupture were thinning or aneurysmal dilatation in 10 patients (66.7%), undermined myocardium in six patients (40.0%), abnormal regional motions in six patients (40.0%), and pericardial hematoma in six patients (40.0%).

Conclusion: Early diagnosis of myocardial rupture after AMI is possible using echocardiographic features on emergency TTE performed by EPs.

Keywords: Complication; Echocardiography; Emergency medical services; Myocardial infarction.

Fig. 1.

Echocardiographic features of myocardial rupture. (A–F) Key features. (G–R) Additional features. (B, D, F, H, J, L, N, P, R) Schematic drawings of echocardiographic images. (A, B) Pericardial effusion (PE). Parasternal long axis view shows pericardial effusion with diastolic collapse of the right ventricle (RV; arrow) indicating cardiac tamponade in a patient with free wall rupture (FWR). (C–F) Visible defect and shunt. Parasternal short axis view shows a visible defect and shunt flow on the interventricular septum (arrow) in a patient with ventricular septal rupture (VSR). (G, H) Thinning of the myocardium. Parasternal short axis view shows thinning of the interventricular septum (arrow) involved in myocardial rupture in a patient with VSR. (I, J) Aneurysmal dilation. Apical four-chamber view shows an aneurysmal dilation of the apical interventricular septum (arrow) in a patient with combined FWR and VSR. (K, L) False aneurysm. Apical two-chamber view shows undermined myocardium resulting in an aneurysm (arrow) in a patient with FWR. (M, N) Undermined myocardium. Apical long axis view shows dissection of the interventricular septum (arrow) in a patient with VSR. (O, P) Undermined myocardium. Parasternal short axis view shows undermined myocardium resulting in an ulceration (arrow) in a patient with FWR. (Q, R) Pericardial hematoma. Subcostal view shows a pericardial hematoma (arrow) in a patient with FWR. LV, left ventricle; LA, left atrium; RA, right atrium; AO, aorta.

Fig. 2.

Schematic illustrations of an anatomic location involving myocardial rupture. Diagram of left ventricular segmentations shows the anatomic location of (A) free wall rupture (FWR) and (B) ventricular septal rupture (VSR). Colors denote the number of patients. Two patients with both FWR and VSR were included. AA, apical anterior; AI, apical inferior; AL, apical lateral; AS, apical septal; BA, basal anterior; BAL, basal anterolateral; BAS, basal anteroseptal; BI, basal inferior; BIL, basal inferolateral; BIS, basal inferoseptal; MA, mid anterior; MAL, mid anterolateral; MAS, mid anteroseptal; MI, mid inferior; MIL, mid inferolateral; MIS, mid inferoseptal.