Tratamiento intervencionista de las complicaciones mecánicas en el infarto agudo de miocardio / Interventional management of mechanical complications in acute myocardial infarction

Las complicaciones mecánicas posteriores a un infarto agudo de miocardio no son comunes, pero tienen consecuencias dramáticas y potencialmente letales. El ventrículo izquierdo se ve afectado con mayor frecuencia y las complicaciones se clasifican, según su inicio después del evento primario, en tempranas (de días a semanas después) y tardías (de semanas hasta años). A pesar de que la incidencia de estas complicaciones se ha reducido en la era de la angioplastia primaria —allá donde está disponible—, la mortalidad sigue siendo significativa y, aunque estas complicaciones se consideran poco frecuentes, suponen una emergencia y son una importante causa de mortalidad a corto plazo. Los dispositivos de asistencia circulatoria mecánica, en especial implantados de forma mínimamente invasiva y sin necesidad de toracotomía, han mejorado el pronóstico de estos pacientes al facilitar su estabilidad hasta que se pueda aplicar el tratamiento definitivo. Por otro lado, la creciente experiencia en intervenciones percutáneas para el tratamiento de la rotura del septo interauricular y la insuficiencia mitral aguda se ha asociado con una aparente mejora en sus resultados que aún precisa de la obtención de evidencia prospectiva (AU)

Mechanical complications following a myocardial infarction are uncommon, but with dramatic consequences and high mortality. The left ventricle is the most often affected cardiac chamber and complications can be classified according to the timing in early (from days to first weeks) or late complications (from weeks to years). Despite the decrease in the incidence of these complications thank to primary percutaneous coronary intervention programs —wherever this option is available—, the mortality is still significant and these infrequent complications are an emergent scenario and one of the most important causes of mortality at short term in patients with myocardial infarction. Mechanical circulatory support devices, especially if minimally invasive implantation is used avoiding thoracotomy, have improved the prognosis of these patients by providing stability until definitive treatment can be applied. On the other hand, the growing experience in transcatheter interventions for the treatment of ventricular septal rupture or acute mitral regurgitation has been associated to an improvement in their results, even though prospective clinical evidence is still missing (AU)

Interventional management of mechanical complications in acute myocardial infarction.

Mechanical complications following a myocardial infarction are uncommon, but with dramatic consequences and high mortality. The left ventricle is the most often affected cardiac chamber and complications can be classified according to the timing in early (from days to first weeks) or late complications (from weeks to years). Despite the decrease in the incidence of these complications thank to primary percutaneous coronary intervention programs -wherever this option is available-, the mortality is still significant and these infrequent complications are an emergent scenario and one of the most important causes of mortality at short term in patients with myocardial infarction. Mechanical circulatory support devices, especially if minimally invasive implantation is used avoiding thoracotomy, have improved the prognosis of these patients by providing stability until definitive treatment can be applied. On the other hand, the growing experience in transcatheter interventions for the treatment of ventricular septal rupture or acute mitral regurgitation has been associated to an improvement in their results, even though prospective clinical evidence is still missing.

Mechanical complications in STEMI: prevalence and mortality trends in the primary PCI era. The Ruti-STEMI registry.

INTRODUCTION AND OBJECTIVES: Mechanical complications confer a dreadful prognosis in ST-elevation myocardial infarction (STEMI). Their prevalence and prognosis are not well-defined in the current era of primary percutaneous coronary intervention (pPCI) reperfusion networks. We aimed to analyze prevalence and mortality trends of post-STEMI mechanical complications over 2 decades, before and after the establishment of pPCI networks. METHODS: Prospective, consecutive registry of STEMI patients within a region of 850 000 inhabitants over 2 decades: a pre-pPCI period (1990-2000) and a pPCI period (2007-2017). We analyzed the prevalence of mechanical complications, including ventricular septal rupture, papillary muscle rupture, and free wall rupture (FWR). Twenty eight-day and 1-year mortality trends were compared between the 2 studied decades. RESULTS: A total of 6033 STEMI patients were included (pre-pPCI period, n=2250; pPCI period, n=3783). Reperfusion was supported by thrombolysis in the pre-pPCI period (99.1%) and by pPCI in in the pPCI period (95.7%). Mechanical complications developed in 135 patients (2.2%): ventricular septal rupture in 38 patients, papillary muscle rupture in 24, and FWR in 73 patients. FWR showed a relative reduction of 60% in the pPCI period (0.8% vs 2.0%, P<.001), without significant interperiod changes in the other mechanical complications. After multivariate adjustment, FWR remained higher in the pre-pPCI period (OR, 1.93; 95%CI, 1.10-3.41; P=.023). At 28 days and 1 year, mortality showed no significant changes in all the mechanical complications studied. CONCLUSIONS: The establishment of regional pPCI networks has modified the landscape of mechanical complications in STEMI. FWR is less frequent in the pPCI era, likely due to reduced transmural infarcts.

Temporal trends in postinfarction ventricular septal rupture: the CIVIAM Registry.

INTRODUCTION AND OBJECTIVES: Postinfarction ventricular septal rupture is a rare but severe complication of myocardial infarction with high mortality rates. Our goal was to analyze which factors could have an impact on mortality due to this entity over the past decade, including those related to mechanical circulatory support. METHODS: The CIVIAM registry is an observational, retrospective, multicenter study carried out in Spain. We designed a comparative analysis, focused on description of in-hospital management and in-hospital and 1-year total mortality as the primary endpoints, dividing the total observation time into 2 equal temporal periods (January 2008 to June2013 and July 2013 to December 2018). RESULTS: We included 120 consecutive patients. Total mortality during this period was 61.7% at 1-year follow-up. Patients in the second period were younger. One-year mortality was significantly reduced in the second period (75.6% vs 52.7%, P=.01), and this result was confirmed after adjustment by confounding factors (OR, 0.40; 95%CI, 0.17-0.98). Surgical repair was attempted in 58.7% vs 70.3%, (P=.194), and percutaneous closure in 8.7% and 6.8%, respectively (P=.476). Heart transplant was performed in 1 vs 5 patients (2.2% vs 6.8%, P=.405). The main difference in the clinical management between the 2 periods was the greater use of venoarterial extracorporeal membrane oxygenatiom in the second half of the study period (4.4% vs 27%; P=.001). CONCLUSIONS: Postinfarction ventricular septal rupture still carries a very high mortality risk. There has been a progressive trend to increased support with venoarterial extracorporeal membrane oxygenatiom and greater access to available corrective treatments, with higher survival rates.

[Jugular vein perforation by a peripherally inserted central catheter]. / Perforación de vena yugular por un catéter venoso central de inserción periférica.

INTRODUCTION: Peripherally inserted central catheters (PICC) are increasingly used in patients who require intravenous access for a long time. We present a 53-year-old male patient with an advanced distal esophageal cancer who suffered a potentially serious mechanical complication after insertion of a PICC.

INTRODUCCIÓN: Los catéteres venosos centrales de inserción periférica (PICC) son cada vez más utilizados en pacientes que requieren un acceso intravenoso durante un tiempo prolongado. Presentamos un paciente de 53 años de edad con cáncer de esófago distal avanzado que sufrió una complicación mecánica potencialmente grave tras la inserción de un PICC.

Rotura subaguda de la pared libre del ventrículo izquierdo en el contexto del infarto agudo de miocardio / Subacute rupture of the free wall of the left ventricle during acute myocardial infarction / Ruptura subaguda da parede livre do ventrículo esquerdo no contexto do infarto agudo do miocárdio

La rotura subaguda de la pared libre del ventrículo izquierdo es una complicación rara del infarto de miocardio, cuya incidencia se encuentra disminuida considerablemente en los últimos años, debido a las terapias de reperfusión. Presentamos el caso de un paciente de sexo masculino de 65 años de edad que ingresó a nuestro hospital, derivado de otro centro médico, con diagnóstico presuntivo de taponamiento cardíaco en el curso de un infarto ínfero-pósterolateral sin tratamiento de reperfusión. Se discute la presentación clínica, los factores de riesgo, los métodos de diagnóstico y la conducta quirúrgica.

Subacute rupture of the free wall of the left ventricle is an infrequent complication of myocardial infarction; the incidence is considerably diminished in the last few years due to reperfusion therapies. We report the case of a male patient aged 65 years was admitted to our hospital, derived from another medical center, with presumptive diagnosis of cardiac tamponade in the course of an infero-posterolateral infarction without reperfusion therapy. Clinical presentation, risk factors, methods of diagnosis and surgical management are discussed.

A ruptura subaguda da parede livre do ventrículo esquerdo é uma complicação rara do infarto do miocárdio, a incidência é diminuída consideravelmente nos últimos anos devido às terapias de reperfusão. Nós relatamos o caso de um paciente do sexo masculino com 65 anos internado em nosso hospital, derivado de outro centro médico, com diagnóstico presuntivo de tamponamento cardíaco no curso de um infarto ínfero-póstero-lateral sem terapia de reperfusão. Discutimos a apresentação clínica, os fatores de risco, os métodos de diagnóstico e o tratamento cirúrgico.

Complicaciones mecánicas del infarto: rotura de pared libre ventricular. Presentación de un caso / Mechanical complications of myocardial infarction: ventricular free wall rupture. Report of a case

En los pacientes con síndrome coronario agudo, dos terceras partes de los casos fallece sin alcanzar a recibir atención hospitalaria (principalmente en las primeras dos horas) debido a la muerte súbita. Del tercio restante, el 50% lo hará en las 24 horas siguientes a su ingreso hospitalario, principalmente debido a las complicaciones mecánicas del infarto. Actualmente, la identificación y estratificación inmediata del paciente con síndrome coronario agudo, el papel de las unidades coronarias y la reperfusión temprana (farmacológica o mecánica) en los casos indicados, han demostrado disminuir la morbimortalidad por cardiopatía isquémica. Dentro de las complicaciones mecánicas del infarto, la ruptura de pared libre ventricular se presenta en el 5-10% de los pacientes hospitalizados que fallecen por infarto agudo del miocardio con elevación del segmento ST. Se presenta un caso clínico con estas características.

In patients with acute coronary ischemic syndrome, two-thirds of cases die without reaching hospital care (mainly in the first two hours) due to sudden death. Of the remaining third, 50% will do so within 24 hours of hospital admission, mainly due to mechanical complications of infarction. Currently, the identification and early stratification, the role of coronary care units and early reperfusion (pharmacologic or mechanical) where indicated, have been shown to decrease morbidity and mortality from ischemic heart disease. Within the mechanical complications of infarction, ventricular free wall rupture occurs in 5-10% of hospitalized patients dying of acute myocardial infarction with ST segment elevation. We report a case with these features.

Factores de riesgo para las complicaciones mecánicas inmediatas de la cateterización venosa central en pacientes del Servicio de Emergencia del Hospital Nacional Arzobispo Loayza, Diciembre 2013 - Marzo 2014 / Risk factors for the immediate mechanical complications of the central venous catheterization in patients of the Emergency Service at the National Hospital Arzobispo Loayza, December 2013 - March 2014

Objetivo: Determinar cuáles son los factores de riesgo para las complicaciones mecánicas inmediatas de la cateterización venosa central en pacientes atendidos en el Servicio de Emergencia del Hospital Nacional Arzobispo Loayza durante el período diciembre 2013 a marzo del 2014. Metodología: Estudio observacional, analítico de casos y controles, prospectivo, transversal. El estudio se realizó a 149 pacientes con indicación de colocación de catéter venoso central. Las pruebas estadísticas utilizadas fueron la Chi-cuadrado y el Odds ratio con interpretación significativa un nivel de confianza del 95 por ciento. Resultados: Del estudio realizado la mayoría de los pacientes tenía entre 31 a 50 años (48.3 por ciento), la mayoría de sexo femenino (53.0 por ciento). La mayoría de pacientes acudieron a la unidad de shock - trauma (58.4 por ciento). Respecto a las características anatómicas de los pacientes, el 61.7 por ciento utilizó ventilación mecánica, mientras que el 60.4 por ciento de pacientes la distancia tiro mentoniana fue >6.5 cm, el 57.0 por ciento tenía una distancia esterno-mentoniana >12.5 cm. Asimismo, el 84.6 por ciento tuvo una altura del cuello mayor a 5 cm. También, en el 85.9 por ciento se identificó el borde posterior del musculo esternocleidomastoideo. Además, de encontrar escaso tejido celular subcutáneo en el 16.8 por ciento de pacientes. La colocación del catéter venoso a los pacientes lo realizó principalmente el residente de intensivo o emergencia (56.4 por ciento), el 34.2 por ciento residentes de otra especialidad y el 9.4 por ciento asistente intensivista o emergenciólogo. Asimismo, el 46.3 por ciento conocía y ejecutaba de 2 a 3 accesos venoso centrales, seguido de 30.2 por ciento que conocía de 4 a 5 accesos venosos centrales, el 20.8 por ciento conocía 6 accesos venosos centrales, solo un 2.7 por ciento conocía y ejecutaba un acceso venoso central. Respecto a las características de la cateterización en cuanto al acceso venoso central...

Objective: To determine the risk factors for immediate mechanical complications of central venous catheterization in patients attending in the Emergency Services Archbishop Loayza National Hospital during the period December 2013 to March 2014. Methodology: Observational, analytical case-control, prospective, transversal study. The sample was 149 patients with indication for central venous catheter placement. Statistical tests used were the Chi-square and odds ratio with interpretation significant confidence level of 95 per cent. Results: Most of the patients were between 31-50 years (48.3 per cent), mostly female sex (53.0 per cent). Most of patients went to the unit of shock - trauma (58.4 per cent). Regarding the anatomical features of the patient, 61.7 per cent used mechanical ventilation, while 60.4 per cent of patients thyromental distance was >6.5 cm, 57.0 per cent had a sterno-mentonian distance >12.5 cm. Similarly, 84.6 per cent had a neck height greater than 5 cm. Also, in 85.9 per cent the posterior border of the stemocleidomastoid muscle was identified. Moreover, in 16.8 per cent of patients little subcutaneous tissue was found. Venous catheter placement in patients was primarily made by intensive resident or emergency (56.4 per cent), 34.2 per cent residents of other specialty and 9.4 per cent intensivist assistant or emergency room doctor. Also, 46.3 per cent knew and ran 2 to 3 central venous access, followed by 30.2 per cent who knew 4-5 central venous access, 20.8 per cent knew 6 central venous access, only 2.7 per cent knew and ran a central venous access. Regarding the characteristics of the catheterization about the central venous access, the most frequent was infraclavicular (59.1 per cent), and the right side was the most frequent site (75.2 per cent). The reason for choosing the access was mainly by operator preference (84.6 per cent). In addition, the reason for catheter placement was mainly by vasoactive drugs (55.0 per cent). In most...

Ruptura miocárdica y formación de aneurisma después de un infarto agudo de miocardio silente: reporte de un caso / Myocardial rupture and aneurysm after an acute, silent myocardial infarction: a case report

Los aneurismas ventriculares y la ruptura del septum interventricular son complicaciones del infarto agudo del miocardio que pueden acompañarse de alta morbimortalidad. Se reporta el caso de un paciente con formación y ruptura de un aneurisma verdadero de la pared inferior y del septum interventricular inferior después de un infarto agudo de miocardio silente. Se discuten las características clínicas, diagnóstico y manejo de estas complicaciones potencialmente letales.

Ventricular aneurysms and interventricular septal rupture are complications of acute myocardial infarction and thesecomplications may have a high morbidity and mortality. We report the case of a patient with an aneurysm involving theinferior myocardium and the inferior interventricular septum following an acute silent myocardial infarction. The clinicalcharacteristics, diagnosis and management of these potentially lethal complications are discussed.

Cirugía de revascularización miocárdica en pacientes con síndrome coronario agudo: análisis de resultados / Coronary artery bypass graft surgery in patients with acute coronary syndrome: analysis of results

Objetivo: identificar los principales factores de riesgo que influyen en el pronóstico, resultados, tipo y tasas de morbilidad y mortalidad de los pacientes con síndrome coronario agudo sometidos a cirugía de revascularización miocárdica. Material y métodos: se trató de un estudio retrospectivo de pacientes sometidos a cirugía por síndrome coronario agudo de enero de 2000 a diciembre de 2003. Se identificaron factores demográficos, indicación de cirugía, enfermedades intercurrentes, resultados de la intervención, morbilidad y mortalidad, y se compararon con escalas internacionales. Resultados: fueron 73 varones y 23 mujeres, la edad osciló entre 46 y 88 años. Predominó la angina inestable (42.7 %). Dos pacientes fueron operados por angioplastia coronaria percutánea fallida y 28 por complicaciones mecánicas del infarto del miocardio. La cirugía fue realizada como urgencia en 90.6 %. La mayoría de los pacientes estuvieron en clasificación Killip-Kimball y Forrester I y II. Los factores de riesgo detectados fueron falla del ventrículo izquierdo, complicaciones mecánicas, cirugía de emergencia, diabetes y falla respiratoria o renal. La mortalidad perioperatoria fue de 14.5 % y la morbilidad de 41.6 %, que comparadas con la clasificación de riesgo de nuestros pacientes fueron más bajas que las esperadas, según las escalas de Parsonnet y Tuman. Conclusiones: aunque el mayor número de factores de riesgo y valores más altos en las escalas de riesgo empeoran en forma importante el pronóstico, en nuestro centro los resultados obtenidos con el tratamiento quirúrgico en síndrome coronario agudo muestran resultados favorables.

BACKGROUND: The objective of this work was to determine the main risk factors that influence prognosis, results, morbidity and mortality rates and causes in patients with acute coronary syndrome requiring surgical myocardial revascularization. METHODS: This was a retrospective study including patients in our hospital with acute coronary syndrome requiring coronary artery bypass-graft surgery between January 2000 and December 2003. The following were identified and compared with international values: demographic factors, indications for surgery, intercurrent pathologies, results of the procedures, morbidity and mortality rates and causes. RESULTS: There were 73 males and 23 females with an age range of 46 to 88 years old. The main cause of surgery was unstable angina (42.7%). In two patients, surgery was indicated for percutaneous coronary angioplasty failure and in 28 patients due to mechanical complications of acute myocardial infarction. The procedure was urgent in 90.6%. The majority of patients were in Killip-Kimball or Forrester class I or II. Risk factors detected were left ventricular failure, mechanical complications, emergency surgery, diabetes and respiratory or renal failure. Perioperative mortality was 14.5% and morbidity was 41.6%, both compared with risk classification scales and were lower than expected according to Parsonet and Tuman evaluations. CONCLUSIONS: With a major number of risk factors and the high-risk associated with surgery, in our center surgical treatment for acute coronary syndromes showed favorable results.

Complicaciones mecánicas relacionadas al uso de catéteres venosos centrales: revisión bibliográfica e imágenes / Mechanical complications in the use of imaging central venous catheters

Los catéteres venosos centrales son un recurso terapéutico fundamental debido al advenimiento de unidades de pacientes críticos, donde se utilizan para control de variable hemodinámicas, administración de drogas y nutrición parenteral; a la masificación de la hemodiálisis, siendo una herramienta transitoria previo a la obtención de accesos definitivos y para pacientes oncológicos, con el objetivo de administración de quimioterapia. Sin embargo, el uso de catéteres venosos centrales no es inocuo. En la literatura se reportan diversas complicaciones. Dentro de éstas, las mecánicas son frecuentes, presentándose el 5-19 por ciento de los pacientes. Las complicaciones más prevalerte son la punción arterial, hemotórax y neumotórax. El objetivo de esta revisión es actualizar conceptos básicos relacionados a las complicaciones mecánicas asociadas a la instalación de catéteres venosos centrales y mostrar imágenes obtenidas en el servicio de imagenología de nuestro hospital, correspondientes a ocho pacientes que presentaron alguna de éstas.

Central venous catheters are important therapeutic resources nowadays, because of the development of critical care units, where these devices are aimed to monitorize hemodynamic parameters and to administrate drugs and parenteral nutrition to patients; massification of hemodyalisis, where central venous catheters are used as transitory accesses before the definitive ones are obtained and in the oncologycal setting, to administrate chemotherapeutic drugs to patients. Nevertheless, the use of such devices is not harmless. Several complications are reported in current literature. Mechanical complications are frequent and they are found in 5-19 percent of patients in whom central venous catheters are installed. According to their prevalence, the most important are arterial puncture, hemothorax and pneumothorax. This review is aimed to update basic concepts regarding to mechanical complications associated to the use of central venous catheters and to show radiological images from eight patients who presented to the imagenology department of our hospital with such complications.