Section: USMLE

56) A 65 year-old man is admitted to the coronary care unit with a diagnosis of a large myocardial infarct (MI) of the left ventricle. On his 6th postinfarct day, he goes into shock and dies, manifesting signs and symptoms of cardiac tamponade. Which of the following complications is the most likely cause of this patient’s death?

1. Aortic dissection
2. Extension of previous MI
3. Fatal arrhythmia
4. Rupture of the left ventricular wall
5. Rupture of papillary muscle

Rupture of the free left ventricular wall is a frequently fatal complication that may occur in the first week after myocardial infarction (MI). At this stage, the infarcted area is composed of friable necrotic myocardium and early granulation tissue. It is during this crucial phase, therefore, that rupture usually occurs. Blood rushes out, filling the pericardial sac and causing compression of the left ventricle. Cardiac tamponade ensues, and the patient usually dies of acute cardiogenic shock.

Aortic dissection is not a complication of MI, although cardiac tamponade may also follow this acute condition when dissection works its way back toward the aortic root. Aortic dissection usually develops in aortas affected by cystic medial degeneration (CMD), which is due to fragmentation of elastic laminae with accumulation of myxoid material in the aortic media. CMD may be either sporadic or associated with Marfan syndrome.

Extension of a previous MI may occur in the first few hours or days after MI. It may aggravate or precipitate cardiogenic shock and/or arrhythmias, but it does not cause cardiac tamponade.

Arrhythmias are frequent complications of MI and are often fatal, producing cardiac arrest (ventricular fibrillation) or aggravating cardiac dysfunction.

If infarction involves papillary muscles, these may rupture. This complication is followed by valvular dysfunction and may manifest with signs of mitral regurgitation and acute congestive heart failure.