Active pericardial hemorrhage is of critical clinical significance because it can rapidly lead to cardiac tamponade and, without timely intervention, result in cardiac arrest. The differential diagnosis for hemopericardium includes iatrogenic injury, chest trauma, aortic dissection, post-infarction rupture of the free ventricular wall, and malignant neoplasms.^[1] Distinguishing each of these conditions requires conducting various invasive and noninvasive diagnostic evaluations. However, transthoracic echocardiography is the preferred method because it is fast, accurate, and applicable at the bedside. It can also provide a functional assessment of tamponade, which is life-threatening. Therefore, diagnosis or even suspicion of cardiac rupture is an indication for emergency surgery without delay.

Ventricular free-wall rupture (VFWR) following acute myocardial infarction (AMI) is a rare and catastrophic complication. In the era of early reperfusion therapy, VFWR occurs in less than 1% of AMI patients.^[2] A thorough understanding of the mechanical complications of AMI and a rapid diagnosis are key to successfully treating VFWR. The clinical presentation and outcome of VFWR largely depend on the rupture’s location, size, and timing.^[3] Although acute VFWR is often fatal, several reports describe conservative treatment strategies.^[4–6] These approaches may be considered in specific cases; however, the therapeutic choice for patients with acute VFWR remains emergency surgical intervention.

The direct suture repair technique was introduced in 1972 by Montegut and colleagues.^[7] Subsequently, various patch-based repair techniques were presented^[8,9] until Padró and colleagues described the first series of 13 patients successfully treated with a sutureless approach involving an epicardial patch and tissue glue in 1993.^[10] Despite the long-standing history of treating this infarction-related complication, the scientific literature still reports high in-hospital postoperative mortality rates ranging from 17% to 36%.^[11–13] The choice of surgical approach remains debatable, with techniques primarily divided into sutured and sutureless approaches. No consensus has yet been reached on which approach leads to better survival outcomes; however, the desire to improve patient survival rates has stimulated further clinical research.

The aim of this study was to present our experience treating post-infarction rupture of the ventricular free wall. Specifically, we examined the relationship between preoperative risk factors and patient survival. Additionally, we aimed to compare our perioperative outcomes with those reported in the scientific literature.

Prior to the routine implementation of early reperfusion strategies, the mechanical complications of ST-segment elevation myocardial infarction (STEMI) were relatively common, with free wall ruptures occurring in 1% to 6% of cases.^[14] The primary risk factors for this condition include advanced age, female sex, first transmural myocardial infarction, prolonged angina with persistent ST-segment elevation, elevated systolic blood pressure, excessive intrahospital physical activity, low body mass index, and delays in reperfusion therapy.^[15,16] Free-wall rupture typically occurs within the first seven days following an acute myocardial infarction.^[17] Science literature describes two types of wall rupture based on the timing of onset: early rupture, which develops within the first 48 hours, and late rupture, occurring after the second day. Early forms account for approximately 50% of cases, although the actual frequency may be higher when considering patients who die before reaching the hospital.^[18]

The urgent nature of the condition dictates that transthoracic echocardiography serves as the primary diagnostic method, thanks to its rapid applicability at the bedside. Common findings in patients with ventricular rupture include reduced myocardial wall thickness, hemopericardium, and cardiac tamponade.^[19] If necessary, cardiac magnetic resonance imaging can supplement the diagnosis by identifying localized ventricular rupture.^[20] Computed tomography also allows for the assessment of potential causes of hemopericardium, including myocardial wall rupture. While these highly specialized diagnostic methods can provide greater clarity regarding the condition and its localization, the critical nature of myocardial infarction complications often precludes their use. The clinical presentation typically features chest pain, anxiety, hemodynamic instability, or cardiogenic shock. More than 80% of patients present with evidence of cardiac tamponade, including pulsatile jugular venous distension, muffled heart sounds, or paradoxical pulse.^[21] Despite the high potential of diagnostic investigations, the definitive diagnosis is usually established in the operating room.

The therapeutic algorithm for patients with ventricular rupture begins with volume resuscitation and hemodynamic support. Mechanical ventilation and primary decompressing pericardiocentesis are typically utilized when necessary, with the aim of providing time for transport to the operating room. Performing percutaneous coronary angiography prior to surgical intervention is rarely feasible. Opinions on this matter are conflicting, and some authors argue that revascularization positively impacts survival rates, while others recommend avoiding coronary angiography in favor of expedience.^[21] Intraoperative placement of an intra-aortic balloon pump (IABP) is a commonly employed approach aimed at achieving hemodynamic stabilization and reducing wall stress. Surgical techniques are categorized into two main types: sutured and sutureless. The choice of surgical technique is individualized, and according to the literature, postoperative mortality rates are similar between the two techniques.^[11] The results of our study did not favor one technique over the other, as survival using the different methods did not reach statistical significance (p=0.292).

Given the low incidence of this complication, most studies are limited to single-center retrospective analyses with relatively small sample sizes. Authors report advanced age (over 70 years), female sex, and lower rates of percutaneous coronary intervention (PCI) as risk factors for rupture.^[21] In 2021, Matteucci published a large multicenter study involving 148 patients operated on in 16 hospitals performing cardiac surgery in the Netherlands. The results indicated a higher prevalence of males (54.7%) and a mean age of 66.5±11.1 years.^[22] Our demographic data are similar, with males again representing a higher frequency at 58.3% and a mean age of 72.92±13.09. A critical preoperative status in Matteucci’s study was recorded in 62.6% of patients, with an in-hospital mortality rate of 31.1%.^[22] The results of the conducted analysis identified female sex and critical preoperative status as independent predictors of in-hospital mortality.^[22]

The results of our study are similar to those published by Matteucci. Preoperative cardiogenic shock is observed in 75% of cases, and the in-hospital mortality rate is 25%. There is a minimal difference in patient survival when compared based on critical preoperative status. Additionally, the frequency of the male population is three times higher in the non-survivor group. We examined preoperative laboratory indicators: hemoglobin, troponin, CPK, and CPK-MB, which likely correlate with survival. The only indicator that reached statistical significance as a predictor of in-hospital mortality was the higher levels of creatine phosphokinase in the non-survivor group, measuring 695.67±279.55 compared to 323.00±179.44 in the survivor group, with p=0.021. This difference may be attributed both to the larger infarct area and to the time elapsed since its onset. Statistically speaking, the length of hospital stay is significantly shorter in the non-survivor group (p<0.001), but this relationship is inverse (as the shorter hospital stay was due to the occurrence of mortality). All other investigated indicators did not achieve significance and cannot be used as predictors of in-hospital mortality.

The retrospective design of the study, the small sample size, and the absence of a control group represent significant limitations. Additionally, the extended study period introduces the potential for heterogeneity in treatment practices, which may lead to an overestimation of the results’ significance. Future research should validate these findings through larger, more comprehensive studies.

Successful management of ventricular free-wall rupture requires a thorough understanding of acute myocardial infarction and its mechanical complications, with rapid response from emergency physicians potentially saving lives. Immediate surgical repair of the ventricular wall is fundamental to the therapeutic approach, and effective communication among the various members of the Heart Team can help reduce perioperative risk to some extent. The choice of surgical technique remains individualized for each patient, with no significant correlation with survival. Levels of creatine phosphokinase may serve as a predictor of survival, but further studies are needed to confirm this trend.