Ventricular Rupture (Left Ventricular Free Wall Rupture)

What ventricular rupture is

The left ventricle pumps blood to the body under high pressure. During a heart attack, part of its muscle dies. Over the following days, white blood cells clear the dead tissue before scar forms, and the wall is at its thinnest and weakest. If the wall gives way, blood bursts into the pericardium, the tight sac around the heart.

Because the pericardium cannot stretch quickly, even a small amount of blood squeezes the heart and stops it filling. This is called cardiac tamponade. Blood pressure collapses, often within minutes.

Ventricular rupture is one of three types of cardiac rupture. The others are rupture of the wall between the ventricles (septal rupture) and rupture of a papillary muscle that anchors the mitral valve. The free wall type is the most common and the most lethal.

Types of free wall rupture

A pseudoaneurysm differs from a true ventricular aneurysm, which is a bulge of thinned scar that still contains heart muscle and rarely ruptures.

Causes and risk factors

Heart attack

Most cases follow a heart attack (myocardial infarction). The risk is higher with:

• a first heart attack, especially without previous chest pain (fewer protective collateral vessels)
• a large, full-thickness (transmural) infarct, often of the front or side wall
• late treatment, no treatment, or failed opening of the blocked artery
• age over 70 and female sex
• high blood pressure during the first days after the heart attack
• use of steroids or NSAIDs around the time of the heart attack

With prompt angioplasty and stenting, free wall rupture now occurs in well under 1% of heart attacks. It remains an important cause of early death after heart attack, particularly in people who arrive late.

Other causes

• blunt chest trauma, such as a steering wheel injury (see cardiac contusion)
• penetrating chest injuries
• complications of heart procedures, such as catheter, valve or pacemaker procedures
• severe heart infection (endocarditis) with abscess
• rarely, tumors, sarcoidosis or stress cardiomyopathy

Symptoms and signs

Ventricular rupture typically strikes someone who seemed to be recovering from a heart attack:

• sudden return of chest pain, sometimes sharp or worse with breathing, from blood irritating the pericardium
• nausea, vomiting, restlessness and anxiety
• sweating, pale or gray skin
• fainting or near-fainting
• sudden very low blood pressure and a fast pulse
• distended neck veins and muffled heart sounds (signs of tamponade)
• abrupt loss of consciousness with cardiac arrest in which the ECG shows electrical activity but there is no pulse (pulseless electrical activity)

Some people with a subacute rupture have warning signs such as recurrent pain, unexplained low blood pressure or vomiting for hours beforehand.

Diagnosis

• Bedside echocardiogram: the key test. It shows fluid around the heart, signs of tamponade, and sometimes the tear itself or a pseudoaneurysm.
• ECG: may show persistent ST elevation or new changes.
• Pericardiocentesis: draining fluid with a needle confirms blood around the heart.
• CT or cardiac MRI: for stable patients, especially to characterize a pseudoaneurysm.

Treatment

Ventricular rupture needs immediate action, ideally in a hospital with cardiac surgery:

1. Stabilization: IV fluids, medicines to support blood pressure, and sometimes mechanical support such as ECMO or an intra-aortic balloon pump.
2. Pericardiocentesis: removing some blood from around the heart can relieve tamponade and buy time. It is a bridge, not a cure.
3. Emergency surgery: the surgeon repairs the tear by sewing a patch over it or using a sutureless technique that glues a patch over the damaged area. Bypass grafting may be done at the same time.
4. Pseudoaneurysm repair: surgery is usually recommended soon after diagnosis because of the risk of sudden rupture.

Outlook

Acute blowout rupture is usually fatal before treatment can be given. People with subacute rupture who reach the operating room have a much better chance, and many survive surgery, although the risk of death remains high. Survivors usually do well long-term if the rest of the heart muscle is reasonably preserved. After recovery, they follow the same heart attack care as others: cardiac rehabilitation, medicines, and control of risk factors.

Prevention

The best prevention is fast treatment of heart attacks. Call 911 for heart attack symptoms rather than waiting or driving yourself, because opening the blocked artery within hours limits muscle damage. Control blood pressure in the days after a heart attack and avoid NSAIDs unless a doctor approves.

Frequently asked questions

What causes ventricular rupture?

Most cases follow a large heart attack. Dead heart muscle becomes soft and thin during healing, usually 1 to 5 days later, and can tear under the pressure of each heartbeat. Less often, chest trauma, heart procedures or severe infection cause it.

What are the symptoms of a ruptured ventricle?

Typical signs are a sudden return of chest pain, nausea, sweating, fainting, very low blood pressure and a rapid pulse, often days after a heart attack. A large rupture causes collapse and cardiac arrest within minutes because blood fills the sac around the heart.

Can you survive a ventricular rupture?

Some people do, especially when the tear is small or slow-bleeding and they reach a hospital with cardiac surgery quickly. Emergency drainage and surgical repair can be lifesaving. A sudden large rupture is usually fatal.

What is a left ventricular pseudoaneurysm?

It is a contained rupture: the heart wall has torn, but the leak is sealed by the pericardium and clot, forming a sac outside the heart. It can rupture without warning, so surgical repair is usually recommended once it is found.

How soon after a heart attack can the heart rupture?

Rupture most often occurs within the first 5 days, with peaks in the first 24 hours and again around days 3 to 5. It can occasionally happen up to 2 weeks later, which is why new chest pain or fainting during recovery needs emergency care.