A 55-year-old man is brought to the emergency department of Apollo Hospitals, Indraprastha, New Delhi, by his coworkers after fainting at his workplace. On examination, the patient’s pulse was feeble, and blood pressure was not recordable. At the Emergency Department, the patient was resuscitated and put on a ventilator. On further enquiry, it was found that he had complained of fever and weakness for the preceding two days. He does not have any history of previous heart disease. An ECG did not show any signs of heart attack. But considering the age of the patient and the sudden onset of the condition, the emergency physicians decided to consider a cardiology opinion. The Cardiologist on duty performed an echocardiogram, and the patient was found to have a collection of fluid around the heart, which was interfering with its contractions.
The multidisciplinary team at Apollo hospitals consisting of Cardiothoracic Surgeons, Anesthetists, Cardiologists, Perfusionists, Cardiac nurses and other specialists deliberated over the patient’s condition and decided upon an emergency open-heart surgery to drain the fluid. The intensive cardiac care team at Apollo hospitals prepared the patient for an emergency pericardiectomy, which involves opening the coverings of the heart and draining the fluid collection. On the operating table, the surgeons discovered that the pericardial sac was filled with blood clots due to the rupture of a heart chamber wall. The left ventricle is an important chamber of the heart. The patient had an inch long tear on the free wall of the left ventricle. The patient was put on the heart-lung machine which performs the functions of the heart and the lung during an open heart surgery. The Surgeon injected potassium to make the heart stop. This technique is called cardioplegia. The rupture of the heart wall was repaired under cardioplegia. At the end of the surgery, the heart-lung machine was discontinued, and the patient’s normal heartbeat and breathing resumed. The patient did not have any complications during or after the surgery.
Rupture of the heart wall or myocardial rupture is a rare but life-threatening condition. In most cases, the condition is immediately fatal, and only a very few patients survive to reach medical care and recover. Causes of heart wall rupture include obstructed blood supply to the heart muscles, trauma, infections, tumors or cancers of the heart, muscle diseases, and malignancies of other organs infiltrating the heart. Patients may experience sudden difficulty in breathing, chest pain, excessive sweating and may collapse. Sudden death is common. Diagnosing a ruptured heart relies tremendously on the skill and experience of the cardiologist. Several investigations can aid in the diagnosis; the most important one is an echocardiogram. A CT or MRI may be performed if required. Prompt surgical repair is the treatment of choice. The ruptured portion of the heart is repaired with patches or biological glue. Early treatment of heart attacks is also necessary to prevent wall rupture.
The worldwide reported incidence of heart wall rupture is low, approximately 2%. Case reports of heart wall rupture from across the world are usually following heart attack (myocardial infarction). Most studies from western countries report a reduction of incidence of this condition due to the advances in the understanding and availability of latest treatments for heart attack. In most advanced centers, surgical management of heart rupture is performed. This requires the availability of an experienced and skilled surgical team that specializes in cardiothoracic surgery.
The present case was highly complicated due to the fact that it was a concealed ruptured. Yet we were able to save the patient’s life due to prompt diagnosis and management. The patient made a full recovery after surgery and was discharged from the hospital after 2 weeks. Follow- up evaluation showed the normal functioning of his heart and he was able to resume his normal activities.