Article

lock Open Access lock Peer-Reviewed

1

Views

ARTIGO ORIGINAL

Rotura cardíaca após infarto agudo do miocárdio (IAM): uma complicação passível de correção cirúrgica?

Luís Alberto DallanI; Sérgio Almeida de OliveiraI; Carlos Abreu FilhoI; Richard H CabralI; Fábio B JateneI; Paulo M Pêgo-FernandesI; José Carlos R IglésiasI; Marcelo B JateneI; Geraldo VerginelliI; Adib D JateneI

DOI: 10.1590/S0102-76381993000400005

RESUMO

Foram estudados 9162 pacientes atendidos no INCOR, com o diagnóstico de IAM, de janeiro de 1983 a dezembro de 1993. Destes, 1,05% apresentaram rotura cardíaca de origem isquêmica como complicação do infarto miocárdico. A faixa etária média foi de 69,5 anos, predominando os pacientes de raça branca (93,75%) e do sexo feminino (55,3%). Os dados estudados incluíram história clínica, exames laboratoriais subsidiários, drogas utilizadas e achados cirúrgicos ou de necropsia. As roturas cardíacas foram classificadas, de acordo com a literatura, em agudas e sub-agudas. Observamos 72 casos de rotura miocárdica aguda com taxa de mortalidade de 98,6% e 24 casos de rotura sub-aguda com 41,6% de óbitos. Foram operados 4 pacientes na forma aguda e 15 na forma sub-aguda, resultando em 78,9% de sobrevida pósoperatória. Dos pacientes que receberam terapia trombolítica com sucesso 76,4% faleceram, enquanto que, dos pacientes tratados convencionalmente, esse número chegou a 86,1 %. Quando a terapia trombolítica foi administrada até 1 hora após o IAM, a mortalidade foi de 33,3%, dentre 3 e 6 horas foi de 60% e após 6 horas foi de 100%. A rotura ocorreu após 5 dias do IAM somente em 5,9% dos pacientes que receberam trombolíticos, enquanto que nos pacientes submetidos à terapêutica convencional esse índice elevou-se para 40,5%. Concluímos pela gravidade e necessidade de atuação imediata nos pacientes com rotura cardíaca, mesmo nos casos sub-agudos, quando 30% dos pacientes com suspeita ecocardiográfica de expansão em área isquêmica transmural falecem. Nas roturas agudas, a situação é dramática e a sobrevida está associada a fatores logísticos. Em condições sub-agudas, entretanto, pode-se dispor de técnicas que dispensam suturas e circulação extracorpórea, constituindo um importante recurso para o tratamento dessa grave complicação do IAM.

ABSTRACT

PURPOSE: Analise the incidence of cardiac rupture within the patients received in our hospital with the diagnosis of AMI in a period of 10 years and try to identify cases when the cardiac rupture can be submitted to a successful approach. METHODS: 9162 patients were received by INCOR with the diagnosis of AMI in the period from January 1983 to december 1993. From these patients 1.05% had cardiac rupture as an ischaemic complication of the myocardium infarction. The average of age was 69.5 years and showing a predominance of white people (93.75%) and female sex (55.3%). Data from patients include clinical history, complementary investigations, drugs used in the treatment and surgical or anatomopathological findings. The cardiac ruptures were classified as acute and sub-acute, according to literature. RESULTS: We found 72 cases of acute myocardial rupture with a mortality rate of 98.6% and 24 cases of sub-acute myocardial rupture with 41.6% of deaths. Four patients were operated on acute rupture and 15 patients were operated on subacute rupture. The post surgery survival was 78.9%. The patients who had a successful thrombolitic therapy, 76.4% died while the others who received routine therapy, 86.1 % passed away. Once the thrombolitic therapy was given until an hour the mortality was 33.3%; from 3 to 6 hours it was 60% and after 6 hours it was 100%. When it turns to the lenght of time of the onset of the cardiac rupture after I AM treatment, it happend after 5 days just in 5.9% of the patients who received trombolitic agents but in 40.5% of the patients with the routine therapy. CONCLUSIONS: We recognized the importance and the necessity of a immediate action for the patient with cardiac rupture even in sub-acute cases when 30% of the patients with an echographic probability of having a progression of the transmural ischaemic area die. In acute ruptures the situation is dramatic and survical depends on logistic factors. In sub-acute conditions however, new sutureless techniques without using extra-corporeal circulation are now available and they will have a huge importance in the treatment of this extremely serious complication of AMI.
Texto completo disponível apenas em PDF.

REFERÊNCIAS

1. AKASAKA, T.; YOSHIKAWA, J.; YOSHIDA, K. - Ventricular free wall rupture following acute myocardial infarction: a two dimensional echocar-diographic assessment. J. Cardiol., 18: 89-97, 1988. [MedLine]

2. ARAUJO, A.; CRAVINO, J.; PERDIGÃO, C. DE LIMA R.; MACEDO, M.; RIBEIRO, C. - Rotura da parede livre do ventrículo esquerdo na fase aguda do enfarte do miocárdio operada com sucesso. Rev. Port. Cardiol., 6: 315-322, 1987.

3. BALAKUMARAN, K.; VERBAAN, C. J.; ESSED, C. E. - Ventricular free wall rupture: sudden subacute slow sealed and stabilized varieties. Eur. Heart J., 5: 282-293, 1984.

4. BATES, R. J.; BEUTLER, S.; RESNEKOV, L.; ANAGNOSTOPOULOS, C. E. - Cardiac rupture: challange in diagnosis and management. Am. J. Cardiol., 40: 429-437, 1977. [MedLine]

5. BATTS, K.; ACKERMANN, D. M.; EDWARDS, W. D. - Postinfarction rupture of the left ventricular free wall: clinicopathologic correlates in 100 consecutive autopsy cases. Human Pathol., 21: 530-535, 1990.

6. CHRISTENSEN, D. J.; FORD, M.; READING, J.; CASTLE, C. H. - Effect of hipertension on myocardial rupture after acute myocardial infarction. Chest., 72: 618-622, 1977. [MedLine]

7. DALLAN, L. A. O.; OLIVEIRA, S. A.; LAVITOLA, P.; VERGINELLI, G.; JATENE, A. D. - Infarto hemorrágico conseqüente à reperfusão miocárdica. Relato de quatro casos. Arq. Bras. Cardiol., 54: 127-132, 1990. [MedLine]

8. DALLAN, L. A.; OLIVEIRA, S. A.; RAMIRES, J. A. F.; SABINO NETO, A.; VERGINELLI, G.; JATENE, A. D. - Tratamento cirúrgico da comunicação interventricular pós infarto agudo do miocárdio. Rev. Bras. Cir. Cardiovasc, 4: 64-74, 1989.

9. DELLBORG, M.; HELD, P.; SWEDBERG, K. - Rupture of the myocardium: occurrence and risk factors. Br. Heart J., 54: 11-16, 1985. [MedLine]

10. DESOUTTER, P.; HALPHEN, C.; HAIAT, R. - Two dimension echocardiographic visualization of free ventricular wall rupture in acute anterior myocardial infarction. Am. Heart J., 108: 1360-1367, 1984.

11. ELIOT, R. S. & EDWARDS, J. E. - Pathology of coronary atherosclerosis and its complications. In Hurst JW, Logue RB, Schlant RC: The Heart: arteries and veins. 4 ed. New York, NY. Mc Graw-Hill, 1978. p. 1121-1134.

12. ENNIX Jr, C. L.; ECKER, R. R.; IVERSON, L. I. - Early detection and management of left ventricular free rupture during acute myocardial infarction. Am. J. Cardiol., 63: 151-152, 1989. [MedLine]

13. FITZGIBBON, G. M.; HOOPER, G. D.; HEGGTVEIT, H. A. - Successful surgical treatment of postinfarction external cardiac rupture. J. Thorac Cardiovasc. Surg., 63: 622-630, 1972. [MedLine]

14. HARVEY, W. - De Circulatio Sanguinis. Exercit 3. Citado por Morgagni GB In: The seats and causes of diseases. Tradução Benjamin Alexander. London, Letter 27, p. 830, 1769.

15. HONAN, M. B.; HARRELL, F. E.; REIMER, K. A.; CALIFF, R. M.; MARK, D. B.; PRYOR, D. B.; HLATKY, M. A. - Cardiac rupture, mortality and the timing of thrombolytic therapy: a meta-analysis. J. A. C. C., 16: 359-367, 1990.

16. ISHIBASHI-UEDA, H.; IMAKITA, M.; FUJITA, H.; KATSURAGI, M.; YUTANI, C. - Cardiac rupture complicating hemorrhagic infarction after intracoronary thrombolysis. Acta Path. Jpn., 42: 504-507, 1992.

17. KAO, K. J.; HACKEL, D. B.; KONG, Y. - Hemorrhagic myocardialinfarction after streptoquinase treatment for acute coronary thrombosis. Arch. Pathol. Lab. Med., 108: 121-124, 1984. [MedLine]

18. KENDALL, R. W. & DE WOOD, M. A. - Postinfarction cardiac rupture: surgical success and review of the literature. Ann. Thorac. Surg., 25: 311-315, 1978. [MedLine]

19. LEONE, A. - Are we able to prevent death due to postinfarction cardiac rupture by early diagnosis and surgical treatment? Jpn. Heart J., 32: 635-644, 1991. [MedLine]

20. LEVENE, A. - Spontaneous rupture of the heart. Br. Heart J., 22: 660-670, 1960. [MedLine]

21. LÓPEZ-SENDÓN, J.; GONZALES, A.; SÁ, E. L.; COMA-CANELLA, I.; ROLDAN, I.; DOMINGUEZ, F.; MAQUEDA, I.; JADRAQUE, L. M. - Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: sensitivity snd specificity of clinical, hemodynamic and echocardiographic criteria - J. A. C. C, 19: 1145-1153, 1992.

22. MANN, J. M. & ROBERTS, W. C. - Rupture of the left ventricular free wall during acute myocardial infarction: analysis of 138 necropsy patients and comparison with 50 necropsy patients with acute myocardial infarction without rupture. Am. J. Cardiol., 62: 847-859, 1988. [MedLine]

23. MATHEY, D. G.; SCHOFER, J.; KUCK, K-H; BEIL, U.; KLOPPEL, G. - Transmural, haemorrhagic myocardial infarction after intracoronary streptoquinase: clinical, angiographic, and necropsy findings. Br. Heart J., 48: 546-551, 1982. [MedLine]

24. MEURS, A. A. H.; VOS, A. K.; VERHEY, J. B.; GERBRANDY, J. - Electrocardiogram during cardiac rupture by myocardial infarction. Br. Heart J., 32: 232-236, 1970.

25. MORGAGNI, J. B. - The seats and causes of diseases investigated by anatomy, vol 1. Tradução de B. Alexander. London, Millar A. Cadell T. 1769; p. 811-834.

26. NAEMIN, F.; DE LA MAZA, L. M.; ROBBINS, S. L. - Cardiac rupture during myocardial infarction: a review of 44 cases. Circulation, 45: 1231-1939, 1972.

27. NAKAJIMA, H. & EDWARDS, J. E. - Factors favoring certain complications of acute myocardial infarction. Minnesota Med., 40: 291-295, 1985.

28. NAKAMURA, F.; MINAMINO, T.; HIGASHINO, Y.; ITO, H.; FUJII, K.; FUJITA, T.; NAGANO, M.; HIGAKI, J.; OGIHARA, T. - Cardiac free wall rupture in acute myocardial infarction: ameliorative effect of coronary reperfusion. Clin. Cardiol., 15: 244-250, 1992. [MedLine]

29. NUNEZ, L.; DE LA LLANA, R.; LÓPEZ-SENDÓM, J.; COMA, I.; GIL AGUADO, M.; LARREA, J. L. - Diagnosis and treatment of subacute free wall ventricular rupture after infarction. Ann. Thorac. Surg., 35: 525-529, 1983. [MedLine]

30. PADRÓ, J. M.; MESA, J. M.; SILVESTRE, J.; LARREA, J. L.; CARALPS, J. M.; CERRÓN, F.; ARIS, A. - Subacute cardiac rupture: repair with a sutureless technique. Ann. Thorac. Surg., 55: 20-24, 1993.

31. PAPPAS, P. J.; CERNAIANU, A. C.; BALDINO, W. A.; CILLEY Jr, J. H.; DELROSSI, A. J. - Ventricular freewall rupture after myocardial infarction: treatment and outcome. Chest, 99: 892-895, 1991. [MedLine]

32. PENTER, P.; GERBAUX, A.; BLANC, J. J.; MORIN, J. F.; JULIENNE, J. L. - Myocardial infarction and rupture of the heart: a macroscopic pathologic study: Am. Heart J., 93: 302-331, 1977.

33. PERDIGÃO, C.; LÓPEZ-SENDÓN, J.; FROUFE, J. - Causas de morte no enfarte agudo do miocárdio: estúdio multicéntrico Ibérico. Rev. Port. Cardiol., 7: 31-35, 1988. [MedLine]

34. RASMUSSEN, S.; LETH, A.; KJOLLER, E.; PEDERSEN, A. - Cardiac rupture in acute myocardial infarction. Acta Med. Scand., 205: 11-16, 1979. [MedLine]

35. REDDY, S. G.; ROBERTS, W. C. - Frequency of rupture of the left ventricular free wall or ventricular septum among necropsy cases of fatal acute myocardial infarction since introduction of coronary care units. Am. J. Cardiol., 63: 906-911, 1989. [MedLine]

36. SCHUSTER, E. H. & BULKLEY, B. H. - Expansion of transmural myocardial infarction: a pathophysiologic factor in cardiac rupture. Circulation, 60: 1532-1538, 1979. [MedLine]

37. SHAPIRA, I.; ISAKOV, A.; BURKE, M.; ALMOG, C. - Cardiac rupture in patients with acute myocardial infarction. Chest., 92: 219-223, 1987. [MedLine]

38. TWINDALE, N.: HENRY, L.; MORPHETT, A.; TONKIN, A. M. - Hemorrhagic myocardial infarction complicated by free wall-rupture: a case associated with unusual clinical features following intravenous thrombolitic therapy. Aust. N. Z. J. Med., 19: 138-140, 1989. [MedLine]

39. VAN TASSEL, R. A. & EDWARDS, J. E. - Rupture of heart complicating myocardial infarction: analysis of 40 cases including nine examples of left ventricular false aneurysm. Chest, 61: 104-116, 1972. [MedLine]

40. WESSLER, S.; ZOLL, P. M.; SCHLESINGER, M. J. - The pathogenesis of spontaneous cardiac rupture. Circulation, 6: 334-351, 1952. [MedLine]

Article receive on quarta-feira, 1 de dezembro de 1993

CCBY All scientific articles published at www.rbccv.org.br are licensed under a Creative Commons license

Indexes

All rights reserved 2017 / © 2024 Brazilian Society of Cardiovascular Surgery DEVELOPMENT BY