Cardiorrhesis

Description:

The cardiorrhesis is a hardest and deadly complication of a myocardial infarction which is registered at 2 – 8% of patients with a myocardial infarction.

Most often cardiorrheses happen in the first 5 – 7 days of a myocardial infarction (the incident for the first time).

On observations of the practicing cardiologists working with patients in infarctive departments, the repeated heart attack is complicated by a cardiorrhesis less often because the hem formed from the previous heart attack is steadier against a lack of oxygen (a hypoxia, ischemia), than not damaged (native) tissue of heart. Therefore there is an opinion that the first heart attack is more dangerous in respect of a gap, than repeated.  

But everything in this world is relative and in each separate case the course of a heart attack can be unpredictable. In order that the nobility to whom the cardiorrhesis threatens more it is necessary to mark out risk factors of development of a cardiorrhesis.

Cardiorrhesis reasons:

Risk factors of a cardiorrhesis include:

Female (women twice more often have cardiorrheses, than at men).

Transmural myocardial infarction (extensive and deep damage of a cardiac muscle).

High arterial pressure (therefore at a myocardial infarction always appoint the medicines reducing arterial pressure, transferring heart to more economical operating mode thereby reduce load of heart and improve process of healing of a cardiac muscle (scarring)).

Absence before stenocardia attacks (i.e. earlier heart did not hurt at all, and the first heart attack, ended with a heart attack).

Late terms of hospitalization (more than 24 hours from the beginning of a myocardial infarction).

Late use of thrombolytic means (the medicines dissolving blood clot which was the reason of a heart attack). Early use of trombolitik and successful recovery of a coronary blood-groove by means of a thrombolysis, reduces the frequency of ruptures of a myocardium and by that improves survival of patients.

Excessive physical activity on the first week of a heart attack (when pain disappears, patients try to be walked up and down quicker to be recovered or simply relax and dare to go outside, walk upstairs and so forth). All this increases load of the injured heart and can lead to a gap.

Early postinfarction stenocardia (the stenocardia attacks arising and which are becoming frequent in the first days after a heart attack).

Reception of hormonal and antiinflammatory drugs because these medicinal substances slow down process of formation of connecting fabric (hem) in the damaged heart zone and by that leave the struck part of a myocardium defenseless before a gap.

Cardiorrhesis symptoms:

Classification of cardiorrheses:
- Early and late
- Outside and internal
- Single-step and slowly current.

Now is more detailed about everyone:

1. Precocious ruptures of a myocardium occur within the first days of a heart attack. The necrosis (dying off) of cells of a cardiac muscle and lack of a hem since in the acute period the hem does not form yet is the reason of a gap. Than more zone of injury of heart by a heart attack (dying off of cells of a myocardium), that high probability of emergence of a gap.
Late ruptures of a myocardium happen for 4 – 7 days from the beginning of a heart attack. It is promoted by stretching and thinning of the nekrotizirovanny (died-off) site of a myocardium which can be provoked by increase in arterial pressure or excessive physical activity.
In other words, heart did not heal yet, and load of it amplifies. It how to gather water in a rubber sphere with a small crack or a hole. In process of  filling by its water, the sphere will stretch and sooner or later will tear.

2. Outside ruptures of a myocardium are ruptures of a wall of a ventricle of heart in the field of its damage with the expiration of blood in a cavity of a pericardium and development of a tamponade.
The pericardium is a cover in which there is heart, and the tamponade is a filling of all cardial cavities with blood (heart at the same time as if chokes with blood and stops).
Outside ruptures of a wall of the ventricle of heart which was injured from a heart attack have the features:

Meet more often at  patients of younger age (38 – 55 years), in comparison with elderly people and at women more often than at men.

The left ventricle of heart is torn more often than right and auricles are very seldom broken off.

Patients with the increased arterial pressure are subject to a cardiorrhesis more, than the patients having normal figures of arterial pressure.

Injury of a myocardium more, than for 20% is high risk of a cardiorrhesis.

It is more often torn front and side walls of a left ventricle of heart.

Gaps occur in terms from the 1st day to the 3rd week of a myocardial infarction, but is more often from 1st to the 4th days.

Gaps are observed more often at the first myocardial infarction.

The outside rupture of a myocardium conditionally is divided into 2 periods:


Predrazryvny period.

At this time the following symptoms are observed:

The megalgia in heart which is often giving to the area between shovels, not stopped (does not pass and does not decrease) after reception of nitroglycerine and even after intravenous administration of narcotic analgetik (morphine).

Quickly shock symptoms which are caused by a cardiac tamponade accrue (falling of arterial pressure, the loss of consciousness, a low pulse, the patient becomes covered by a cold clammy sweat).

On the ECG (electrocardiogram) the characteristic changes (raising of an interval S-T and  emergence or deepening of a pathological tooth of QS in two and more assignments) speaking about expansion of a zone of a heart attack and the forthcoming cardiorrhesis are registered.

Period of a rupture of a myocardium.

Can proceed both suddenly, and in a slowed-up way.

In 90% of cases of all outside cardiorrheses it occurs suddenly!

At this moment quickly there is a cardiac tamponade, blood circulation stops and the gap is shown by the following signs:

Sudden loss of consciousness

Sharply expressed cyanosis (coloring of skin in gray-blue color) the person and an upper half of a trunk

Cervical veins bulk up and the neck is considerably thickened

Arterial pressure and pulse disappears

In 1 minute breath stops

Pupils extend

On an ECG are registered the wrong rhythm of "wave", passing into an asystolia (the flat line) meaning a full cardiac standstill

Slowly current cardiorrhesis can proceed several hours and even days.

The slow cardiorrhesis occurs when gap size small and in a pericardium cavity at first follows a small amount of blood. In this case, the gap can stop for some time (an incomplete gap). In such situation the flowed-out blood in a small amount turns into blood clots which together with a pericardium limit further intake of blood.

Slowly current cardiorrhesis is followed by the following manifestations:


Megalgia in heart not stopped (not acting) nitroglycerine and narcotic analgetika.

Cardiac pain periodically accrues, then weakens in itself, then amplifies again.  

The patient becomes covered by a cold clammy sweat, skin of gray color, a low pulse, arrhythmia, systolic (upper) arterial pressure very low, and diastolic (lower) can reduce to zero.

If the gap stops (blood clots are formed), these symptoms decrease and arterial pressure is stabilized.

Changes on the cardiogram are identical to an ECG the picture described  at  sudden cardiorrheses.

In spite of the fact that the gap proceeds slowly, patients often perish. However in certain cases manage to carry out a pericardiocentesis and urgent operation on recovery of integrity of a left ventricle, and in case of need, with additional coronary shunting.

Internal cardiorrheses.

Treat internal cardiorrheses:

Rupture of an interventricular partition and papillary muscle.

Rupture of an interventricular partition (MZhP)

This gap meets in 0,2% of cases of an acute myocardial infarction.

The factors contributing to a rupture of an interventricular partition are:

Advanced age

Arterial hypertension

The extensive myocardial infarction of front departments of a left ventricle of heart with involvement of an interventricular partition, especially if a heart attack was complicated by aneurism

Signs of a rupture of an interventricular partition of heart:

Sudden emergence of the sharp, intensive and not stopped pains in heart.

Cardiogenic shock develops (arterial pressure, a cold clammy sweat sharply falls, skin gains cyanotic color, the patient  faints).

At a rupture of a partition between the right and left ventricle, blood mixes up, cervical veins bulk up, the liver increases and becomes very painful when pressing, hypostasis of shins and feet develops later. In that case there comes death.

For diagnosis of a rupture of MZhP carry out the ECHO a cardiography (ultrasonography of heart) at which it is possible to find defect in an interventricular partition.

The forecast at a rupture of MZhP depends on the size of a gap, expressiveness of the phenomena of shock and timeliness of surgical treatment.

At a rupture of MZhP patients can survive if surgical intervention is carried out not later than 48 hours. At small gaps (anguishes), a hemodynamics (arterial pressure, pulse)  can be stabilized, and patients have a chance  to live,  still some time (2 months and even longer).

Rupture of a papillary muscle.

This rare, but often deadly complication of an extensive and deep (transmural) myocardial infarction.

The rupture of a papillary muscle of a right ventricle of heart meets extremely seldom.

The complete separation of a papillary muscle of a left ventricle of heart is incompatible with life because there is the wrong distribution of blood and the rough fluid lungs develops. It is not possible to save the patient in this case.

At an anguish of a papillary muscle, patients can live up to 2 weeks longer and have to be operated.

Symptoms of a rupture of a papillary muscle of a left ventricle of heart following:
Sharp resuming of not stopped pains in heart.
Bystry development of shock (the ABP sharply falls, the patient faints, the low pulse, then disappears).
The severe short wind passing into a suffocation attack then develops cough with department of a foamy phlegm of pink color.

Treatment of a cardiorrhesis:

Treatment of cardiorrheses exclusively surgical. Achievements of a heart surgery allowed in certain cases at timely diagnosis to perform successful operations at internal cardiorrheses: closing of defect of an interventricular partition, plastic or prosthetics of the mitral valve.

It should be noted that an operative measure yields much more favorable result if it is carried out not in the acute period, and later — in 1 month or more from the beginning of a disease. Unfortunately, to this term a considerable part of patients with internal cardiorrheses, especially a separation of papillary muscles, perishes from a circulatory unefficiency. For fight against it resort to a combination of medicamentous and non-drug means now.

If the decompensation is moderately expressed, happens rather usual treatment by cardiac glycosides and diuretics. But at considerable mitral regurgitation or the expressed blood shunting from left to right it is not enough. Moreover, powerful influences can increase regurgitation (or shunting) and to promote the progressing falling of minute volume.

For fight against this phenomenon widely use peripheral vasodilators which, reducing resistance to emission, reduce blood regurgitation, increase cordial emission. It is natural that in such cases it is necessary to prefer as the drugs influencing generally on an arterial part of a vascular bed (phentolamine, Sodium nitroprussidum).

When initially this complication proceeds with the expressed hypotension, try to combine peripheral vazodilatator with the powerful inotropic agent — a dopamine. If such therapy does not give necessary effect, resort to an artificial circulatory support (kontrapulsation). In these most hard cases the attempt of operational treatment is carried out, as a rule, according to vital indications to non-optimal terms (next few days) and with smaller probability of success. Treatment of external cardiorrheses is so far almost inefficient.