Left ventricular unloading therapy using Impella 5.5 after emergency surgery for acute myocardial infarction mechanical complication: a case report.

BACKGROUND: Following an acute myocardial infarction (AMI), surgery for left ventricular free wall rupture (LVFWR) and ventricular septal rupture (VSR) has a high in-hospital mortality rate, which has not improved significantly over time. Unloading the LV is critical to preventing excessive stress on the repair site and avoiding problems such as bleeding, leaks, patch dehiscence, and recurrence of LVFWR and VSR because the tissue is so fragile. We present two cases of patients who used Impella 5.5 for LV unloading following emergency surgery for AMI mechanical complications. CASE PRESENTATION: A 76-year-old male STEMI patient underwent fibrinolysis of the distal right coronary artery. Three days later, he passed out and went into shock. Echocardiography revealed a cardiac tamponade. We found an oozing-type LVFWR on the posterolateral wall and treated it with a non-suture technique using TachoSil. Before the patient was taken off CPB, Impella 5.5 was inserted into the LV via a 10 mm synthetic graft connected to the right axillary artery. We kept the flow rate above 4.0 to 4.5 L/min until POD 3 to reduce LV wall tension while minimizing pulsatility. On POD 6, we weaned the patient from Impella 5.5. A postoperative cardiac CT scan showed no contrast leakage from the LV. However, a cerebral hemorrhage on POD 4 during heparin administration complicated his hospitalization. Case 2: A diagnosis of cardiogenic shock caused by STEMI occurred in an 84-year-old male patient, who underwent PCI of the LAD with IABP support. Three days after PCI, echocardiography revealed VSR, and the patient underwent emergency VSR repair with two separate patches and BioGlue applied to the suture line between them. Before weaning from CPB, we implanted Impella 5.5 in the LV and added venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for right heart failure. The postoperative echocardiography revealed no residual shunt. CONCLUSIONS: Patients undergoing emergency surgery for mechanical complications of AMI may find Impella 5.5 to be an effective tool for LV unloading. The use of VA-ECMO in conjunction with Impella may be an effective strategy for managing VSR associated with concurrent right-sided heart failure.

Ventricular Pseudoaneurysm and Free Wall Rupture After Acute Myocardial Infarction: JACC Focus Seminar 4/5.

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review.

Suspected colchicine-induced late myocardial rupture occurring after the late presentation of acute inferior ST-elevation myocardial infarction.

Colchicine is one of the established drugs of choice for post-myocardial infarction (MI) induced pericarditis, given its anti-inflammatory properties. Recently, colchicine received FDA approval for secondary prevention of atherosclerotic cardiovascular disease, which leads to concerns regarding its anti-healing effects on myocardial tissue post-infarction. We present a case of a suspected colchicine-induced myocardial rupture in an elderly male, who presented with a syncopal episode while on colchicine three weeks after the late presentation of infero-posterior ST-elevation myocardial infarction.

Echocardiography in the Recognition and Management of Mechanical Complications of Acute Myocardial Infarction.

PURPOSE OF REVIEW: Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. RECENT FINDINGS: The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.

Post-infarction Left Ventricular Free Wall Rupture Diagnosed by Contrast-Enhanced Computed Tomography: A Case Report.

A 70-year-old Japanese woman with hypertension, dyslipidemia, and diabetes mellitus complained of abdominal discomfort and vomiting and was brought to our emergency department by ambulance two days later with impaired consciousness. Her vital signs suggested shock with a heart rate of 120 bpm. Electrocardiogram and initial transthoracic echocardiography suggested an inferior wall ST-elevation myocardial infarction, but the altered consciousness was inconsistent. Contrast-enhanced computed tomography was urgently performed to further clarify the cause. It revealed pericardial effusion and apparent extravasation from the left ventricular wall, confirming the early definitive diagnosis of left ventricular free wall rupture. The patient underwent successful emergent surgical repair without sequelae. Differential diagnosis of left ventricular free wall rupture is important in patients with ST-elevation myocardial infarction and impaired consciousness. Contrast-enhanced computed tomography allows early diagnosis and treatment of this life-threatening complication.

Long-term survival after surgical treatment for post-infarction mechanical complications: results from the Caution study.

BACKGROUND AND AIMS: Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study early and long-term results of patients undergoing surgical treatment for post-AMI MCs. METHODS: Patients undergone surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centers worldwide were retrieved from the database of CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality. RESULTS: The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5 and 10 years was 54.0%, 48.1% and 41.0%, respectively. Older age (p < 0.001) and postoperative LCOS (p < 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significant higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022). CONCLUSIONS: Contemporary data from a multicenter cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate postoperative period is encouraging.Trial registration number: NCT03848429.

Successful surgical treatment of left ventricular free wall rupture.

Left ventricular free wall rupture (LVFWR) is a rare mechanical complication of acute myocardial infarction. The clinical course of LVFWR is very poor. Direct or patch closure of the rupture area and sutureless procedures constitute the treatment for LVFWR. We present the surgical treatment of a patient who developed LVFWR after high lateral myocardial infarction, and its successful outcome. Successful salvage of LVFWR remains relatively rare. Transthoracic echocardiography, myocardial contrast echocardiography and thoracic computed tomography are important diagnostic tools for LVFWR. These patients usually present with acute cardiac tamponade symptoms requiring immediate treatment.

Right Ventricular Free Wall Rupture Due to Displaced Automatic Implantable Cardioverter Defibrillator (AICD) Lead.

The implantation of an implantable cardioverter defibrillator (ICD) carries a risk for major complications, one of which is ventricular free wall rupture secondary to a lead perforation. This known complication, although rare, has estimated incidence rates between 0.1% and 3%. Predictive factors of such an event include temporary leads, steroid use, active fixation leads, low body mass index (<20 kg/m2), age greater than 80 years, female gender, and concurrent anticoagulation. Right ventricular systolic pressure >35 mmHg is considered a protective factor likely due to associated right ventricular hypertrophy. We present a case of a 73-year-old female with a history of aortic stenosis status post-transcatheter aortic valve replacement (TAVR) and atrial fibrillation (AFib) who met the criteria for an ICD after suffering ventricular fibrillation arrest (after TAVR procedure) ultimately resulting in lead perforation.

A case of ECPELLA-supported treatment for post-infarction cardiac rupture.

The efficacy and risk of a combination of veno-arterial extracorporeal membrane oxygenation and Impella (Abiomed, Inc., Danvers, MA, USA), an approach known as ECPELLA, for post-infarction cardiac rupture is unclear. We describe the case of a 72-year-old man who presented with acute myocardial infarction. The patient was managed with ECPELLA because of hemodynamic compromise. One week later, there was a sudden increase in venous oxygen saturation. Transthoracic echocardiography revealed ventricular septal rupture, and free wall rupture. Intraventricular thrombus was also observed despite standard anticoagulation therapy. Even with double cardiac rupture, ECPELLA could facilitate left ventricular unloading and sustain hemodynamics. However, because of the risk of device failure due to thrombus aspiration into the Impella, the patient underwent repair surgery. Postoperatively, the patient was temporarily weaned off ECPELLA, and his hemodynamics deteriorated again, and he finally died. Learning objectives: ECPELLA can effectively stabilize the hemodynamics in cases of post-infarction cardiac rupture. However, there are still challenges to address, such as determining optimal ventricular reloading and ECPELLA management for intraventricular thrombus prevention. When using ECPELLA to delay surgery for post-infarction cardiac rupture, it is crucial to strike a balance between hemodynamic stabilization and avoiding potential serious complications.

Up against the wall - emergency double myocardial rupture repair.

BACKGROUND: Left ventricular free wall rupture (LVFWR) and interventricular septal rupture (VSR) are potentially catastrophic mechanical complications after acute myocardial infarction (AMI). When they occur together, "double myocardial rupture" (DMR), survival is unlikely. DMR is seen in only 0.3% of all AMIs. With or without surgical intervention, the odds are against the patient. CASE PRESENTATION: A 57-year-old male self-referred to the emergency department of a remote hospital 5 days after first experiencing chest pain. Investigations in ED confirmed an inferior ST-segment elevation myocardial infarction (STEMI) complicated by DMR. Coronary angiography revealed a mid-course total occlusion of the right coronary artery (RCA). He was rapidly transferred to our regional cardiac surgical unit, arriving straight into the operating theatre, in cardiogenic shock. He was briefly conscious, before arresting prior to intubation and being massaged onto bypass. Not only did he survive the all-night operation, requiring a mitral valve replacement in the process, but he survived multiple postoperative complications to be eventually transferred on postoperative day 66, neurologically intact, to a peripheral unit to complete his rehabilitation. He was subsequently discharged home 88 days after the operation and was able to ambulate with a walking frame into his first postoperative follow-up clinic appointment. CONCLUSIONS: Our patient, against all odds, has survived DMR and multiple postoperative complications. We present the details of his case and the literature surrounding the condition. The patient's mental fortitude and his supportive family played a significant role, along with excellent multidisciplinary team work, in assuring his survival.

Successful conservative treatment for left ventricular free wall rupture after acute myocardial infarction.

Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days.

Sutureless repair of left ventricular free wall rupture following acute myocardial infarction with cardiogenic shock.

We report a case of blow-out-type left ventricular free wall rupture (LVFWR) after acute myocardial infarction, who presented with unstable hemodynamic condition in New York Heart Association (NYHA) functional class IV. Immediately, we performed a successful LVFWR repair with sutureless technique using a glue and expanded polytetrafluoroethylene patch on cardio-pulmonary bypass support. Postoperative period and recovery was uneventful. Over a period of 2-year follow-up, the patient is in NYHA class I and cardiac magnetic resonance imaging showed adequate left ventricular (LV) function and no evidence of LV aneurysm.

Post-Myocardial Infarction Free-Wall Rupture: Rapid Diagnosis and Management.

We present a case of post-myocardial infarction free-wall rupture in a critically ill patient presenting to the emergency department. Through our case we highlight the prompt evaluation, diagnosis, and management necessary to improve survival in a patient with this life-threatening condition. (Level of Difficulty: Beginner.).

Left ventricular pseudoaneurysm without antecedent myocardial infarction.

A left ventricle pseudoaneurysm (LVPA) occurs when the left ventricle free wall rupture becomes contained by pericardium or adhesions. It is rare and has a poor prognosis. LVPA is strongly associated with myocardial infarction. Surgical management of LVPA carries a high mortality rate but is still recommended for most cases of LVPA as soon as the diagnosis is confirmed. Medical management is generally limited to asymptomatic, incidentally found lesions. We present a case of LVPA without any usual risk factors, which was successfully treated by surgery. Learning objectives: •To identify the left ventricle pseudoaneurysm (LVPA) that can present with chest pain or dyspnea, but at times can be asymptomatic•To keep a high index of suspicion for LVPA even in patients without the common risk factors such as recent myocardial infarction, cardiac surgery, or trauma•To realize that management options are individualized•To understand that despite a high surgical mortality, for large expanding LVPA, surgery is still recommended•Further research needs to be done to establish management guidelines.

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)

Spontaneous Coronary Artery Dissection Complicated by Left Ventricular Free Wall Rupture in Turner Syndrome.

A 38-year-old with Turner syndrome presented with acute myocardial infarction due to multivessel spontaneous coronary artery dissection (SCAD) complicated by left ventricular free wall rupture. Conservative management for SCAD was pursued. She underwent sutureless repair for an oozing-type left ventricular free wall rupture. SCAD has not been previously reported in Turner syndrome. (Level of Difficulty: Advanced.).

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.

Factors associated with in-hospital mortality from free wall rupture after acute myocardial infarction.

BACKGROUND: Free wall rupture is a fatal and emergency complication of acute myocardial infarction. The factors associated with in-hospital mortality from free wall rupture remain unclear. OBJECTIVES: To investigate the factors associated with in-hospital mortality from free wall rupture. METHODS: We performed a single-center, retrospective study. We enrolled 111 consecutive patients with free wall rupture following acute myocardial infarction who were admitted to Fuwai Hospital from January 2005 to May 2021. The primary endpoint was in-hospital death. Clinical characteristics, laboratory data, and treatment modalities associated with in-hospital mortality were analyzed. RESULTS: Eighty-seven of the 111 study participants died in hospital. Multivariate Cox regression analysis showed that pericardiocentesis (hazard ratio [HR] 0.296, 95% confidence interval [CI] 0.094-0.929, p = 0.037), pericardial effusion at admission (HR 0.083, 95% CI 0.025-0.269, p<0.001), time interval between acute myocardial infarction and free wall rupture (HR 0.670, 95% CI 0.598-0.753, p<0.001), and previous myocardial infarction (HR 0.046, 95% CI 0.010-0.208, p<0.001) were independently associated with in-hospital mortality. CONCLUSIONS: Pericardiocentesis, pericardial effusion at admission, the acute myocardial infarction to free wall rupture time, and previous myocardial infarction are associated with a lower rate of in-hospital mortality from free wall rupture after acute myocardial infarction.

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.