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We report two cases of type III rupture of the left ventricle posterior wall, situated midway between the mitral annulus and the posterior papillary muscle and occurring in immediate continuations of a mitral valvular replacement. The first case has occurred at the moment of the canulas removal in a 28 years old patient operated for mitral stenosis. The tear was repaired with horizontal mattress sutures through felt strips on the external surface of the heart. The immediate post operative course was marked by bleeding recurrence and cardiac failure which has led to death. In the second case, a 68 years old man was operated for degenerative mitral insufficiency. The rupture has occurred just before closing the chest. The repair was realized successfully by using an intra-ventricular patch. The chordae tendinae removal constitutes a factor predisposing to the left ventricle posterior wall rupture. The repair has to use an intra-ventricular patch. The prevention is based on the preservation of the continuity between the mitral annulus and papillary muscles by preserving the sub-valvular apparatus or by using synthetic chordae.

The authors report the cases of two young adults (25 and 27 years) presenting with congenital left ventricular aneurysm or diverticulum with healthy coronary arteries. This saccular evagination of the ventricular wall is rare. The authors describe a classification distinguishing muscular (contractile) diverticula, composed of the three cardiac tunics, fibrous diverticula and finally aneurysms with a dyskinetic wall. Although the limits of this classification are sometimes poorly defined, it presents a prognostic value, because it appears logical to propose nonsurgical management in the context of muscular diverticula and it seems legitimate to operate on fibrous diverticula and aneurysms due to the risks of rupture, extension, thrombosis or arrhythmia.

The authors report their experience with a simple and efficient technique for repair of left ventricular free wall rupture complicating myocardial infarction. The technique consists, with the aid of cardiopulmonary bypass, in suturing a plaque of the patients own pericardium (6 to 8 cm in diameter) to the more normal tissue encircling the pathologic myocardium, and by injecting five ml of human fibrin glue as a cement under the pericardium to reinforce the remair and prevent leaking throughout the suture line. With a 10 year follow-up, we are able to be confident with the long term results. The five patients, at the time of operation were aged 46 to 74 years. The post-operative results and the annual echocardiographic controls have proved the technique to be sound without recurrences and without late complications such as pseudo aneurysms at the site of the repair.

Two cases of right ventricular free wall rupture secondary to mediastinitis after cardiac surgery are reported. This complication is unusual and characterized by the singular mechanism of rupture (traction involving right ventricular free wall and chest adhesion) which occurs during episodes of coughing. Treatment by omentoplasty en sureda favorable outcome in both cases.

This case of rupture of the left ventricular wall in the acute stage of myocardial infarction, presenting clinically as cardiac tamponnade with no electrical signs of transmural infarction, is reported. After cardiac catheterisation and angiography which confirmed the adiastole, the worsening of the patient's condition necessitated pericardial aspiration which showed the presence of a haemopericardium. This led to surgical exploration and to the repair of a cardiac rupture under cardiopulmonary bypass. The authors recall the incidence of cardiac rupture during myocardial infarction, its poor prognosis, the difficulty of preoperative diagnosis, the anatomical features of the infarct which are theoretically favourable for surgical repair and the rarity of survival after surgery which relies essentially on the availability of medicosurgical facilities for very early surgical intervention.

Thirteen patients with myocardial infarction were investigated with two-dimensional echocardiography because of the appearance of signs of cardio-circulatory failure associated with a systolic murmur during the first 15 days following the infarct. The precise diagnosis was obtained by surgical or autopsy examination in 11 cases and by haemodynamic investigations in 2 cases. These mechanical complications were: 8 septal ruptures and 5 cases of acute mitral incompetence, due to papillary rupture in 2 cases and to papillary dysfunction in 3 cases. The 8 cases of septal rupture, complicating 6 cases of anterior infarct and 2 cases of diaphragmatic infarct, were diagnosed by 2-D echocardiography, which revealed 3 apical perforations (one of which was only visible via a sub-costal approach), 3 superior perforations or lacerations, 2 inferior perforations in the middle or the base of the septum; all visible in an apical view of the 4 cavities. The injection of ultrasonic contrast in 4 patients demonstrated negative lavage, which confirmed the diagnosis, in one case, even before the perforation could be visualised. The 2 cases of ruptured papillary muscles were visualised directly on the 2-D echocardiography. However, only one of the three cases of papillary muscle dysfunction was diagnosed by echocardiography. 2-D echocardiography has an important place in the investigation of complicated myocardial infarction, not only as a means of diagnosing ruptures of the septum or papillary muscles, but also to evaluate the deterioration in left ventricular contractile function, which enabled surgical repair without left haemodynamic investigations, in two cases.

A 58 year old patient with no previous cardiac history developed a postero-inferior myocardial infarction, complicated at the 6th hour by parietal rupture leading to acute tamponade. This was diagnosed by echocardiography which showed a compressive pericardial effusion containing large thrombi. Surgery under cardiopulmonary bypass was successful and led to good quality survival, maintained for over 6 months. A recent angiocardiographic control showed the absence of coronary artery lesions. This case is exceptionally rare and demonstrates the value of echocardiography in myocardial infarction complicated by sudden cardiovascular collapse. In addition, in this case, the haemorrhagic nature of the pericardial effusion was demonstrated by the visualization of thrombi in the pericardial space. Their presence would seem to be quite specific of parietal rupture.

Acute rupture of the left ventricular free wall was suspected in a 53 year old hypertensive patient at the 12th hour of primary antero-septo-apical myocardial infarction. He developed acute tamponade with severe cardiogenic shock during his transfer to hospital. Cardiac compression due to hemopericardium was confirmed by M mode echocardiography (pericardial effusion), right heart catheterisation (adiastole and low cardiac output) and pericardial puncture during which several ccs of blood were aspirated leading to a slight improvement in the patient's condition. At operation under cardiopulmonary bypass 2,5 hours after hospital admission, the surgeon found a hemopericardium related to fissuration of an acute apical infarct which was sutured on a Teflon support. The initial postoperative course was complicated by unexplained gastro-intestinal hemorrhage, transient functional renal failure, cardiac failure and mediastinitis, but the final outcome was successful with a follow-up of 24 months. This appears to be the 9th reported case of long-term survival after surgical repair of rupture of the heart in the acute phase of myocardial infarction.

A 40-year old male patient developed inferior myocardial infarction followed by two rare mechanical complications: rupture of the posterior papillary muscle of the mitral valve, which was successfully repaired, and, a few months later, rupture of an early postero-basal aneurysm which proved lethal. On both occasions the diagnosis was provided by echocardiography. The broken aneurysmal area was visualized as being abnormally mobile. This case offers several interesting points. To our knowledge, the association of these two uncommon complications has not yet been reported; the early development of the aneurysm, its location and its course are unusual, and direct echocardiographic visualization of rupture of the heart is exceptional, hence the value of this exploratory method.

The authors report a case of rupture of the free wall of the right ventricle, diagnosed by two dimensional echocardiography. This examination revealed an intrapericardial clot associated with a fissure of the diaphragmatic wall of the right ventricle. This case emphasises the value of two dimensional echocardiography in the acute phase of myocardial infarction for the diagnosis of complications which require urgent surgical treatment.

A case of subacute left ventricular rupture on the 4th day of an inaugural antero-septal infarction in a 63-year old woman is reported. The diagnosis, suggested by cardiovascular collapse with acute tamponade, was confirmed by echocardiography. Haemodynamic stability was maintained by needle aspiration followed by pericardial drainage, and right heart catheterization long enough for the patient to be transported to a Cardiovascular Surgery unit where surgical repair was successfully performed 9 hours after the rupture. The elements for a positive diagnosis, the value of echocardiography, the various surgical procedures and the favourable long-term prognosis in patients operated upon are discussed.

The case reported here concerns a female of 33 who presented, during the course of an acute bacterial aortitis which had been treated, with an inflammatory perforation of the membranous septum. The clinical picture consisted of an association of very severe heart failure with severe aortic incompetence, an apical pansystolic murmur, and atrioventricular conduction defects. Although it was carried out in the presence of active endocarditis (valve cultures positive for streptococci), operative intervention (Patch + Starr) allowed rapid healing and excellent cardiovascular function after a 30 month follow-up period. Careful study of this case and of the eleven others in the literature has enabled us to underline the following points:--the sudden appearance, in a case with infective aortic incompetence, of a gross pansystolic murmur associated with atrial or intraventricular conduction defects, should be taken as suggesting a septal perforation;--examination of the haemodynamic system in such a case runs certain risks, and should never be allowed to delay the operation, which must always be carried out urgently;--despite the unfavourable operative conditions, the results strongly support the need for surgical intervention in these patients in good time.

Over a 10 year period, four cases of post myocardial infarction pseudo-left ventricular aneurysm were observed, two directly arising from the infarct (postero diaphragmatic patients had pseudo-aneurysms which arose inferiorly from true anteroapical aneurysms and underwent surgical resection. Apart from the histological features, a certain number of diagnostic signs merit review: --A clinical course marked by a number of phases (myocardial infarction--pericardial syndrome--true aneurysm complicated or not by arrhythmias--period of stabilisation followed by deterioration due to rapid progression of cardiac failure). -- "Angiographic-like" ultrasonic and isotopic methods complement left ventriculography which confirms the parietal aneurysm and may show three very suggestive signs of pseudo-aneurysm: a narrow communication with the true aneurysm; delayed and prolonged filling of the bulge; inferior extension with localization by pericardial adhesions. Surgery is imperative, the main problem being the extent of resection of the true aneurysm. This is related to the rigid or calcific character of the neck of the pseudo-aneurysm.

The authors base themselves on 5 personal cases and a review of the literature to summarise the clinical and paraclinical features of false aneurysms of the heart. The clinical features differ from those of true aneurysms only slightly. It is only arteriography, which shows up the collar and the slow evacuation of the cavity, which makes the real distinction and argues in favour of operation. The results of surgical treatment have been satisfactory, especially considering the natural outcome, which is always death from rupture.

31 survivors of a group of 49 patients with septal rupture during acute myocardial infarction were operated on average 8 days after the onset of necrosis. The operation was performed after a period of circulatory assistance in 23 cases and consisted of septal reinforcement, closure of the perforation and resection of necrotic tissue. The results were satisfactory in patients operated on early after effective resuscitation (91 p. 100 survival), and better than in the patients operated on after the maximum possible delay (50 p. 100 survival) and in patients in whom poor tolerance of the VSD led to an emergency salvage operation (29 p. 100 survival).

A man aged 62 had an unexpected anterior myocardial infarction, complicated during the thirteenth hour after onset by parietal rupture and consequent acute tamponnade. The diagnosis was confirmed by echocardiography and then by pericardial puncture which allowed enough time for an operation to be undertaken under extra-corporeal circulation. The infarct was resected together with the weakened area of rupture, and the quality of the patient's life has been maintained at an excellent level after one year.

Rupture of the pericardium after closed trauma of the thorax is rare. There are two main clinical presentations: one of severe thoracic trauma with hemothorax requiring an operation which permits the diagnosis, the other of pain and pericardial signs on auscultation which should attract attention. The treatment requires closure of the pericardial tear as a routine owing to the risk of fatal complications due to dislocation of the heart.

The authors report the case of a double rupture of the heart (septal and parietal intrapericardial) on the 5th day of primary transmural anterior myocardial infarction in a 73 year old women. The diagnosis of septal rupture was made after cardiac arrest and the findings of a systolic murmur, and by echocardiography. Intrapericardial free wall rupture was diagnosed at surgery. The incidence, predisposing factors, gravity, prognostic factors and different medico-surgical therapeutic approaches to septoparietal complications of acute myocardial infarction are reviewed.

Age does not seem to influence either the operative mortality or the incidence of mechanical complications of myocardial infarction, although for some authors rupture of the free wall is more frequent in the elderly. On the other hand, post-operative morbidity is higher in the elderly because the acute haemodynamic disturbances involved often aggravate renal, pulmonary and cerebral degenerative lesions. This paper studies the present data on surgical treatment. Two-dimensional echocardiography has improved diagnosis of free wall rupture as well as of the mechanism of mitral insufficiency. The indications for, and duration of, circulatory assistance using an intra-aortic balloon are now well established in mitral insufficiency and interventricular communication. The introduction of cardiac paralysis, the use of low-profile bioprostheses and coronary revascularisation have improved the surgical results of mitral valve replacement. The techniques of closing interventricular communications together with the treatment of aneurysms are now well established. Where aneurysms are concerned, the methods vary depending on whether it is a false or true aneurysm; in the latter case we discuss aneurysmectomy and surgery for arrhythmia. The only contra-indications to this kind of surgery remain senility and the existence of far advanced associated pathology (whether renal, pulmonary, cerebral or neoplastic).

Two cases of interventricular septal rupture (VSR) in elderly patients (71 and 74 years) occurring at the 5th and 12th day of primary postero-inferior myocardial infarction, were reported. The diagnosis was made at 2D echocardiography and confirmed at catheterisation with coronary angiography. Good surgical results were obtained after operation 72 and 12 hours after VSR (9th and 12th infarct days, respectively): the first patient had a good outcome with a 2 year follow-up, but the second patient died in the 55th postoperative day, of renal failure. The authors underline the value of 2D echo in the management of acute myocardial infarction and in the detection of VSR. In addition, the advances in intensive care and surgical techniques allow early and complete cure of cardiac lesions with a low hospital mortality and significant functional improvement, even in the elderly patient.

Asymptomatic myocardial infarctions, which have been observed and reported by some authors, are usually unrecognized and are only detected by chance. The authors report a case of asymptomatic myocardial infarction with heart rupture resulting in death. This unusual clinical presentation of myocardial infarction is discussed and the literature is reviewed.

Thirteen consecutive cases of cardiac hydatic cyst were studied. The cysts were usually multiple, predominantly left ventricular. There were two cases of rupture of left ventricular cysts with systemic embolism, and three ruptures of right ventricular cysts causing pulmonary embolism. The average age of the patients was 31 years: 12 patients lived in regions where hydatid disease was endemic. Other localisations of hydatic disease were found in 7 cases. Two patients were completely asymptomatic. Three patients presented with a tumoral syndrome. The presentation was atypical simulating coronary artery disease in 2 cases, valvular heart disease in 2 cases, pericarditis in 2 cases and bronchopneumonia in 3 cases. The electrocardiogramme showed sinus rhythm in all cases and changes of subepicardial ischaemia in 8 cases and acute cor pulmonale in 3 cases. Chest X-ray showed a localised deformation of the cardiac silhouette in 5 cases and calcification in 4 cases. Direct angiocardiographic signs were present in 2 out of 8 cases; usually there was an indirect image of endocavitary filling defect. The tumour was demonstrated by 2D echocardiography in the three most recent cases. The value of CAT was assessed in the last 2 cases: it was absolutely diagnostic in 1 case of septal localisation. The results were poor in the second case due to the presence of mitral calcification. Twelve patients underwent surgery; there were 3 deaths due to rupture and 1 death before surgery. The clinical presentation of cardiac hydatid disease is very variable and the diagnosis is difficult.(ABSTRACT TRUNCATED AT 250 WORDS)

Forty two cases of complete or incomplete rupture of the free left ventricular wall were reviewed in a group of 136 patients who died of acute myocardial infarction in a Coronary Care Unit and who underwent autopsy examination over a 30 month period. Four groups were distinguished on macro and microscopic features of the rupture based on a previously defined classification established by former studies: type I rupture (13 cases) with an almost direct trajectory with little dissection and bloody infiltration of the myocardium; type II (13 cases) with a multicanalicular trajectory and widespread myocardial dissection and bloody infiltration; type III (9 cases) in which the orifice of rupture is protected by an intraventricular thrombus or a pericardial symphysis; type IV (7 cases) with incomplete epicardial, endocardial or intramyocardial rupture which never was transparietal. The clinical characteristics (age, sex, time interval before admission to the coronary care unit, previous history, ECG location of the myocardial infarcts, clinical course, Killip classification, treatment and ECG changes) and anatomical findings (weight of the heart, presence of haemopericardium, previous infarction or aneurysm, location of the infarct, presence of intraventricular thrombus or ventricular septal defect, number of vessels with over 75 p. 100 obstruction and topographical location of the rupture) were compared. The type I ruptures had smaller infarcts and a quicker terminal illness with rapid evolution to cardiac tamponade. In type II ruptures, the infarcts tended to be bigger, sometimes associated with septal rupture and the terminal illness was longer lasting than in the previous group, reflecting a longer evolution towards cardiac tamponade.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study was to compare two groups of patients admitted consecutively to the Coronary Care Unit in 1972-73 (223 cases) and in 1982-83 (243 cases) for recent myocardial infarction, and followed up for at least 15 days, to try and appreciate the influence of changes in treatment which had taken place during this interval on outcome and mortality. The two groups were comparable with regards to age, sex, time of admission with respect to onset of symptoms, previous vascular disease, and principal coronary risk factors. The clinical presentation of myocardial infarction and its common complications (cardiac failure, arrhythmias) were unchanged at 10 years' interval. The only statistically significant but unexplained difference was the lower proportion of posterior infarctions in 1982-1983 compared to 1972-1973. This decrease was partly due to the increased detection of rudimentary infarcts by more specific enzyme methods. The decrease in the proportion of posterior infarcts probably also explained the lower numbers of atrioventricular blocks. Other differences between the two groups were not statistically significant (slight increase in age, fewer women, lower incidence of cardiac failure). The mortality rate was exactly the same at 20.6%, and the causes of death were identical. The results support those of other rare studies of the same subject showing the lack of effect of recent therapeutic innovations on the majority of patients with myocardial infarction.

Clinical and autopsy study of 100 cases of patients dying during the first 3 weeks of hospitalisation for myocardial infarction revealed the following causes of death: cardiac failure in 59 cases (including 40 of cardiogenic shock), rupture of the heart in 29 cases (24 of rupture of the ventricular wall, 4 of the septum and 1 of a mitral papillary muscle). 4 ventricular arrhythmias and 6 haemorrhagic or embolic complications. In 2 cases, the cause of death could not be accurately determined. In cardiogenic shock, death usually occurred early. It was later in cases of refractory left ventricular failure. Conduction disturbances were much commoner in cases of myocardial infarction complicated by fatal cardiac failure (57.6%) than in the presence of any other complication (17.1%) (p less than 0.001). The responsible infarction was often extensive and recurrent. Rupture of the heart invariably occurred during the first three days of an infarction often initial (p less than 0.001), anterior (apart from septal rupture) and small in size (p less than 0.01). Other complications play only a secondary role in mortality at the present time, in particular arrhythmias, the gravity of which has greatly decreased since the reduction of delays before hospitalisation and improvements in anti-arrhythmic therapy.

Two rare mechanical complications of right ventricular infarction are reported: myocardial dissection and rupture of the RV free wall. The diagnosis was made by 2D echocardiography in both cases. Myocardial dissection resulted in the formation of an oblong, expansive, intraparietal space. The rupture of the RV free wall was visualised as a breach of the continuity of the ventricular wall. These cases underline the importance of 2D echocardiography in the acute phase of myocardial infarction for the diagnosis of these complications.

An original technique has been successfully used to treat a case of major interventricular communication consecutive to a recent, wide antero-septo-apical infarction. This technique derives directly from Guilmet's reconstructive aneurysmoplasty used for chronic fibrous aneurysms of the left ventricle. The distended anterior aspect of the left ventricle was resected, the left border of the ventriculotomy was lowered and attached to the healthy part of the septum and the right border was brought over and sutured to the lateral aspect of the ventricle. The interventricular communication was therefore closed and excluded from the left ventricular cavity, thus theoretically reducing the risk of residual shunt. The post-operative period was uneventful.