Untangling Mechanical Complications ofAcute Myocardial Infarction.

The following case is the first report of successful repair of combined left and right ventricular free wall and ventricular septal rupture. Reports of left ventricular free wall and septal rupture and reports of right ventricular free wall and septal rupture have been published both with and without successful surgical repair. This case demonstrates the presence of left and right ventricular free wall rupture along with septal rupture based upon cardiac catheterization and operative findings. In spite of her severe mechanical complications and prolonged hospital course, the patient is completely functional 1 year after surgical repair.

Mechanical complications following acute myocardial infarction (MI) represent some of the most challenging conditions in contemporary cardiology, often leading to rapid clinical deterioration and high mortality despite advances in reperfusion therapy. These complications span a spectrum of presentations, from early-phase structural disruptions such as ventricular septal rupture, papillary muscle rupture with acute mitral regurgitation (MR), and left ventricular free wall rupture (LVFWR), to later-stage manifestations, including true ventricular aneurysms and pseudoaneurysms. While surgical intervention has traditionally been considered the standard of care, surgical intervention is often associated with prohibitive risk in hemodynamically unstable or frail patients. In this context, transcatheter approaches have gained traction as viable, less invasive alternatives, offering the potential for hemodynamic stabilization, symptom relief, and improved short-term outcomes in selected patients. Nonetheless, data from observational studies and registry-based analyses remain limited, underscoring the need for further research. This review synthesizes the current evidence base and clinical experience related to transcatheter management of mechanical complications after MI, emphasizing patient selection, procedural strategies, device selection, and reported outcomes.

We report the results of surgical repair for postinfarction left ventricular free wall rupture (LVFR) and ventricular septal perforation (VSP) complicating acute myocardial infarction. We experienced 14 LVFRs and 10 VSPs from January 1991 to December 2002. The mean age of patients with LVFR was 74+/-8.1 years. There were 6 oozing cardiac ruptures and 8 blowout cardiac ruptures. An intraaortic balloon pump (IABP) was inserted in 8 patients, and percutaneous cardiopulmonary support (PCPS) was inserted in 5 patients. The mean age of patients with VSP was 72+/-5.1 years. The rupture was located within the anterior septum in 8 patients and within the posterior septum in 2 patients. All patients required IABP, and one of them needed PCPS. We employed a sutureless technique in 8 patients, direct closure in 5 patients, and infarct exclusion in 1 patient with LVFR. Infarct exclusion was conducted in 9 patients, and the da Silva technique was used in 1 patient with VSP. The patient survival rate of LVFR was 36% (blowout 13%; oozing 67%). Residual shunt occurred in 4 patients with VSP postoperatively. The overall survival rate for VSP was 70%. The operative prognosis of blowout cardiac rupture was poor. Good results were obtained with the infarct exclusion technique for patients with VSP. Although some patients had postoperative residual shunts, the infarct exclusion technique was generally a safe and excellent procedure.

Outcome of Percutaneous Intrapericardial Fibrin-Glue Injection Therapy for Left Ventricular Free Wall Rupture Secondary to Acute Myocardial Infarction

Predictors, Outcomes and Impact of Mechanical Circulatory Support of Patients With Mechanical Complications After Acute Myocardial Infarction

A 74-year-old man died of left ventricular free wall rupture 6 days following an acute inferoposterior wall myocardial infarction. His hospital course was complicated by pump failure which proved resistant to inotropic support, diuresis, and percutaneous transluminal coronary angioplasty. At necropsy, extensive amyloid deposition was noted. This case constitutes an unusual clinical setting for myocardial rupture because of the severity of systolic left ventricular dysfunction as well as cardiac amyloidosis.

Left ventricular free wall rupture is an uncommon but catastrophic event following myocardial infarction, and considered the second leading cause of death in acute myocardial infarct. Different types of rupture exist from acute to sub acute types, but prognosis is usually poor. Early recognition and aggressive treatment is recommended. We present a case of a 75-year-old man who was referred to our echo-lab for an out patient evaluation because of 1-week duration of worsening of chest pain. Standard transthoracic echocardiography showed hypokinesia in the apical portion of the anterior wall and basal portion of the inferior wall. The patient complained of shortness of breath immediately after the conclusion of the exam, and soon afterward became unconscious. Renewed echocardiography approximately 1 min after syncope displayed a newly developed echo-lucent rim around the heart consistent with left ventricular free wall rupture. Resuscitation was performed followed by attempts to evacuate the blood by needle aspiration, which failed. Open pericardiocentesis stabilised the patient until surgery could be performed. The patient survived and could be discharged 2 weeks later. This case highlights the fact that rapid and accurate diagnosis is essential if patients with left ventricular free wall rupture are to survive.

Medical Management of Selected Patients With Left Ventricular Free Wall Rupture During Acute Myocardial Infarction

Left ventricular free wall rupture is a dramatic complication of acute myocardial infarction and is presumably responsible for as much as 20–30 % of all infarct-related deaths [1]. Surgical management is essential [2]. Needle pericardiocentesis is the conventional treatment of cardiac perforation [3]. A 79-year-old man in evolving cardiogenic shock (BP 70/40) mmHg, sinus tachycardia (120 beats/ min) was transferred to our regional cardiac center. ECG showed ST-segment elevation in II, III, aVF and V4–6 leads. Emergency coronary angiography was performed, and totally occluded obtuse marginalis and nonsignificant stenosis in others coronary arteries were detected (Fig. 1a). Bedside transthoracic echocardiography (TTE) revealed LV regional wall motion abnormality and cardiac tamponade. Cardiac rupture was detected at the LV apex. TTEguided pericardiocentesis was performed immediately. However, there was no drainage from the catheter. Hemoglobin decrease was approximately 4 mg/dL during this time. We have decided to try percutaneous closure due to lack of 7/24 surgical backup. The procedure was applied in order to gain time; as a bridge for surgery. The procedure was an emergency and the defect size was only measured with transthoracic echo and a standard Amplatzer TorqVue delivery system was used through a 7F sheath. A 10, 5-mm Amplatzer occluder (Amplatzer occluder is from St. Jude Medical) was deployed (Fig. 1b). The operation was finished in 15 min. A subsequent TTE showed the defect was successfully occluded with only a trivial residual leak (Figs. 2a, 3). The patient slightly recovered after the procedure, blood pressure could be recorded but he was still in cardiogenic shock due to the impossibility of removing the agglutinant pericardial effusion. Therefore, the patient was transferred to the operation room (Fig. 2b). A large haemorrhagic pericardial effusion was seen and the entire heart was covered in a thick fibrinous peel. But he died 6 h after the initial chest pain. This case confirms that transcatheter closure of ventricular free wall rupture with an occluder device is a bailout strategy in very skilled centers for selected cardiogenic shock patients in the absence of on-site cardio-thoracic support.

Introduction: Papillary muscle rupture (PMR), ventricular septal rupture (VSR) and cardiac free wall rupture (FWR), are dreaded complications of STEMI and are associated with increased morbidity and mortality. In multiple previous small to intermediate sized studies, TT as compared to P-PCI was associated with an increase in these mechanical complications. However, large scale observational studies are lacking. Methods: Adult admissions with a primary diagnosis of STEMI between 1999 and 2014 were extracted from the NIS using the ICD-9 code 410.x, except 410.7x (NSTEMI). ICD-9-CM procedure codes 36.01 to 36.07, 36.09, 00.66 and 99.10 were used to stratify the extracted data into patients who underwent P-PCI (Time-to procedure function was used to filter PCI performed within first 24 hours of presentation) and those treated with TT. The incidence of PMR (ICD-9 Code 429.6) and VSR (ICD-9 Code 429.71), VSR (ICD-9 Code 429.71) and FWR (ICD-9 Code 429.79) within 30 days of hospitalization were compared between these two groups. We performed multivariate analysis using Cox Proportional Hazard Regression to control for confounders and determine the hazard of all three complications in patients who had undergone P-PCI vs TT, and the relative mortality of these complications by reperfusion strategy. Results: Of the weighted 2,534,019 admissions for STEMIs, 1,335,711 (52.71%) underwent P-PCI whereas 125,009 (4.93%) were treated with TT. Among these, 748 (0.02%) developed PMR, 3122 (0.12%) developed VSR, and 4850 (0.19%) developed FWR. The adjusted hazard for a complication according to reperfusion modality, and the mortality by treatment are depicted below in Table 1. Conclusions: As compared with P-PCI, patient who were treated with TT had a higher risk of mechanical complications, including PMR, VSR and FWR, and a higher mortality associated with each of these complications.

In patients with acute myocardial infarction, left ventricular free wall rupture is an infrequent complication (2–4%) but it is associated with a high mortality from pericardial tamponade.1-8 It accounts for...

Introduction Moderate to severe pericardial effusion (PE) in patients with acute myocardial infarction (AMI) can be associated with a broad spectrum of etiologies like left ventricular free wall rupture (LVFWR) or post- myocardial infarction pericarditis (PMIP). We present a case of successful medical treatment of patient with subacute LVFWR after AMI, initially managed as PMIP. Case Presentation A 60- year- old man with a history of hypertension was admitted with persisting chest pain for 72 hours, with diagnosis of ST- segment elevation AMI of inferior wall. Patient underwent a percutaneous coronary intervention (PCI) of the right coronary artery as the AMI culprit vessel. Two days after PCI patient experienced progressive sharp chest pain, dyspnea and low- grade fever. Clinical evaluation revealed elevated inflammatory markers and pericardial rub. Transthoracic echocardiography (TTE) showed PE up to 10 mm. Patient has been diagnosed and treated as PMIP. During further observation patient had TTE performed repeatedly. Four days after PCI TTE revealed PE of 20 mm thickness and suspicion of subacute LVFWR of the lateral wall. Cardiac magnetic resonance (CMR) confirmed the diagnosis. Due to hemodynamic stability, the patient received only medical treatment. During further hospitalization TTE was performed every day. On fifteenth day both TTE and CMR didn’t reveal any rupture. Moreover patient was readmitted 6 weeks after initial hospitalization and TTE again did not show the LVFWR. Discussion Post AMI patients with PE who fulfill pericarditits diagnostic criteria should be managed as having PMIP. Nevertheless LVFWR should also be considered as frequent diagnosis of PE. Echocardiography is crucial in the prompt diagnosis of PE. In our presented case, the TTE did not show initially the LVFWR, only repeatedly performed investigation showed the increasing amount of PE and raised suspicion of subacute LVFWR, which was confirmed in CMR. CMR has become a tool providing accurate diagnosis and visualization of the localization of rupture. Moreover CMR imaging can show LVFWR revealing whether the hematoma is circumscribed to the myocardium or communicates with ventricular cavity or the pericardial sac. LVFWR is a catastrophic complication accounting for a significant proportion of in-patient deaths. It is accepted that emergent surgical repair is the cornerstone treatment for patients with LVFWR. However, similarly to ours, some cases with fairly good survival rates following isolated medical treatment have been reported. This clinical situation stands somewhere between the insidious free rupture into the pericardial cavity and the formation of the pseudoaneurysm. Conclusions Our presentation illustrates the usefulness of repeated multimodality imaging for the diagnosis and follow up of patients with PE after AMI. Our case also underscores the value of a conservative approach as a valid alternative to surgery in some patients with subacute LVFWR.

Usefulness of sinus tachycardia and ST-segment elevation in V5 to identify impending left ventricular free wall rupture in inferior wall myocardial infarction

Between August 1992 and February 1998, 43 patients were treated with percutaneous cardiopulmonary support (PCPS) in our institution, and 8 of them subsequently required emergency cardiac surgery. There were 3 males and 5 females with a mean age of 63 years (range, 37 to 81 years). The etiology of shock in these 8 patients was acute myocardial infarction in 3, postinfarction left ventricular (LV) free wall rupture in 1, postinfarction ventricular septal perforation (VSP) in 1, LV free wall rupture and VSP in 1, and fatal arrhythmia due to severe aortic valvular disease in 2. The mean time interval from the onset of cardiogenic shock to the institution of PCPS was 77 min (range, 18 to 183 min). The mean time interval from the institution of PCPS until surgery was 145 min (range, 40 to 603 min). The surgical procedures were coronary artery bypass grafting (CABG) in 3 patients, closure of the LV rupture and/or closure of VSP in 3, and aortic valve replacement in 2. Six patients were weaned from PCPS, and 2 patients were discharged from the hospital (discharge rate, 25%). Although the results of emergency cardiac surgery following PCPS still are not satisfactory, we continue to apply PCPS and perform appropriate surgical procedures to improve the survival rate of the patients who would die without PCPS.

Mechanical complications of acute myocardial infarction which may lead to heart failure or shock include rupture of left ventricular free wall, ventricular septum and papillary muscle. The clinical characteristics of these lesions vary considerably according to the lesion sites. Trea- tment of these complications with medical conservative management alone has high mortality rate, for which reason surgical repair of these defects are essential. Structural defects, including rupture of the left ventricular free wall, ventricular septum, and papillary muscle, account for 5% to 20% of all deaths from acute myocardial infarction. Among these, ventricular septal defects occur in approxi- mately 1% of all myocardial infarctions, and account for up to 2% of deaths subsequent to myo- cardial infarction. Rupture of the ventricular septum following acute myocardial infarction(AMI is associated with high mortality rate, as 54% of the patients succumb within two weeks, 87% within two months and 92.5% during the first year. We experienced two cases of postinfarct ventricular septal defects(VSD which had been repaired within 1 week after AMI due to progressive deterioration of patients' conditions, and were to be reoperated because of repeated septal ruptures in postoperation period and development of cardiogenic shock.