ConditionHeart & circulation
Cardiac Rupture
Cardiac rupture is a tear through part of the heart muscle, most often the wall of the left ventricle, the wall between the ventricles (septum), or a papillary muscle that holds a valve. It usually happens within the first week after a heart attack, when the dead muscle is weakest, or rarely after severe chest trauma. It causes sudden collapse, shock or acute heart failure and is often fatal without emergency surgery. Prompt treatment of heart attacks has made it much less common.
Also called: Myocardial rupture, heart wall rupture, ventricular free wall rupture, ventricular septal rupture, papillary muscle rupture
At a glance
- What it is
- A tear in the heart wall, septum or a papillary muscle.
- When it happens
- Usually 1 to 7 days after a heart attack, especially without prompt reperfusion.
- Frequency
- Rare in the modern era of rapid artery-opening treatment, well under 1% of heart attacks.
- Signs
- Sudden chest pain, collapse, shock, severe breathlessness or a new loud murmur.
- Treatment
- Emergency surgery, with temporary support devices; outcomes are poor without surgery.
When to get help
Call 911 or go to the ER
- Chest pain, pressure or tightness lasting more than a few minutes, especially with sweating, nausea or breathlessness: call 911
- Sudden collapse, fainting or severe breathlessness in someone who has recently had a heart attack
- A return of chest pain, restlessness or a sense of doom in the days after a heart attack
- Sudden severe breathlessness with frothy sputum after a heart attack
See a doctor within a day or two
- Any heart attack symptoms that came and went in the past days but were never checked
Book a routine appointment
- Follow-up after a heart attack to monitor heart function and take prescribed medicines
Types of cardiac rupture
| Type | What tears | What happens |
|---|---|---|
| Free wall rupture | The outer wall of the left ventricle | Blood fills the sac around the heart (cardiac tamponade), causing sudden collapse; sometimes a slow leak or contained rupture (pseudoaneurysm) |
| Ventricular septal rupture | The wall between the left and right ventricles | Blood shunts from left to right, causing sudden heart failure, shock and a new loud murmur |
| Papillary muscle rupture | A muscle anchoring the mitral valve | Sudden severe mitral regurgitation, with fluid flooding the lungs |
Why it happens
After a heart attack, the area of dead muscle softens as the body clears it, before scar tissue forms. Between about day 1 and day 7, the softened area can tear under the pressure of each heartbeat. Rarely, rupture follows blunt chest trauma (for example a car crash), heart infections, tumors or procedures.
Risk factors
- A first heart attack, especially a large ST-elevation heart attack
- Delayed or no treatment to reopen the blocked artery
- Older age, particularly over 70
- Female sex
- High blood pressure at the time of the heart attack
- No previous heart attacks or angina, so no collateral circulation
- Late use of clot-busting drugs, or NSAIDs and steroids around the time of the heart attack (associated in older studies)
Symptoms
- Recurrent or worsening chest pain
- Sudden severe shortness of breath, especially lying flat
- Fainting or collapse
- Low blood pressure, cold clammy skin and confusion (cardiogenic shock)
- Rapid heartbeat
- Sudden cardiac arrest
Doctors may hear a new harsh murmur with septal or papillary muscle rupture. A free wall rupture may cause a sudden drop in blood pressure with distended neck veins and a slowing heart rate, then cardiac arrest.
Diagnosis
- Echocardiogram (heart ultrasound): the key test; shows fluid around the heart, a septal defect, or a flail mitral valve leaflet.
- ECG: shows the heart attack pattern.
- Right heart catheterization: can confirm a left-to-right shunt.
- CT or MRI in stable people with a suspected contained rupture.
Treatment
Cardiac rupture is a surgical emergency.
- Stabilization: fluids, medicines to support blood pressure and reduce strain on the heart, and mechanical support such as an intra-aortic balloon pump, Impella device or ECMO.
- Pericardiocentesis: draining blood from around the heart can buy time in free wall rupture.
- Emergency surgery: repairing the wall with patches, closing a septal defect, or repairing or replacing the mitral valve, often combined with bypass grafting.
- Catheter-based closure of septal defects in selected people.
Outlook
Free wall rupture is fatal in most cases, though some people with a contained or slowly developing rupture survive with surgery. Ventricular septal rupture and papillary muscle rupture have high mortality without surgery, and surgery itself carries substantial risk, but survivors can recover well. The most effective protection is fast treatment of the heart attack itself.
Prevention
- Call 911 immediately for heart attack symptoms; every minute counts.
- Rapid reopening of the blocked artery with angioplasty and stenting greatly reduces the risk of rupture.
- Control high blood pressure, cholesterol and diabetes, and do not smoke, to prevent heart attacks.
Frequently asked questions
What is cardiac rupture?
Cardiac rupture is a tear in the heart muscle, usually after a heart attack. It can occur in the outer wall of the heart, the wall between the two ventricles, or a papillary muscle supporting the mitral valve. It is a life-threatening emergency.
When does cardiac rupture happen after a heart attack?
It usually occurs within the first week, most often in the first 1 to 5 days, when the damaged muscle is softest. It is more likely after a large first heart attack that was not treated quickly to reopen the blocked artery.
Can you survive a heart rupture?
Some people survive, especially with septal or papillary muscle rupture or a contained free wall rupture, if emergency surgery is possible. Sudden complete free wall rupture is usually fatal. Prompt heart attack treatment has made rupture much rarer.
What are the warning signs of cardiac rupture?
Warning signs include new or worsening chest pain, sudden severe breathlessness, fainting, very low blood pressure, cold clammy skin and confusion in the days after a heart attack. Anyone with these symptoms needs emergency care immediately.
Sources
This guide was written from current patient and clinical guidance, including:
- American Heart Association/American College of Cardiology: Guideline for the management of ST-elevation myocardial infarction
- American Heart Association: Mechanical complications of acute myocardial infarction (scientific statement)
- MedlinePlus (US National Library of Medicine): Heart attack
- Merck Manual Professional Version: Complications of acute coronary syndromes
- National Heart, Lung, and Blood Institute (NHLBI): Heart attack