Rotura cardíaca após infarto agudo do miocárdio (IAM): uma complicação passível de correção cirúrgica? Cardiac rupture after acute myocardial infarction (AMI): may it have a surgical repair?

Abstract

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.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.

Keywords

• coração
• infarto do miocárdio
• agentes trombolíticos
• myocardial infarction
• thrombolitic agents