Surgical Repair of Mechanical Complications of Myocardial Infarction

Mechanical Complications of Myocardial Infarction

In this retrospective observational study, we have examined the incidence, characteristics, and treatment of serious myocardial infarction (MI) -associated mechanical complications (MCs) occurring in Japanese patients in this era of percutaneous coronary intervention (PCI), focusing on frailty, nutrition, and clinical implication of surgery. Included were 883 patients who, having suffered an MI, had been admitted to Nihon University Hospital between January 2013 and April 2020. Fifteen (1.70%) of these patients had suffered a potentially catastrophic MC-ventricular free wall rupture (VFWR, n = 8), ventricular septal rupture (VSR, n = 6), or papillary muscle rupture (PMR, n = 1). Factors associated with the MCs were age, poor nutritional status, a high Killip class, delayed diagnosis of MI, a high lactate concentration, a low thrombolysis in myocardial infarction flow grade, and single-vessel disease. Thirty-day mortality among MC patients was 60% (9/15): 87.5% associated with VFWR, 33.3% associated with VSR and 0% associated with PMR. On adjusted multivariate analysis, occurrence of an MC was independently associated with 30-day mortality. Despite a high surgical risk (EuroSCORE II: 11.8 ± 4.7) with less frailty, 30-day mortality was lower among patients whose MC was treated surgically than among those whose MC was treated conservatively (40.0% versus 100.0%, respectively; P = 0.044).Our data suggest that surgical intervention can save patients with a life-threatening MI-associated MC and should be considered, if they are not particularly frail.

Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction (from APEX-AMI)

A decrease in mechanical complications after ST-elevation myocardial infarction may have contributed to improved survival rates associated with reperfusion by primary percutaneous coronary intervention (PCI). Mechanical complications occurred in 52 of 5,745 patients (0.91%) in the largest reported randomized trial in which primary PCI was the reperfusion strategy. The frequencies were 0.52% (30) for cardiac free-wall rupture (tamponade), 0.17% (10) for ventricular septal rupture, and 0.26% (15) for papillary muscle rupture (3 patients had 2 complications). Ninety-day survival rates were 37% (11) for cardiac free-wall rupture, 20% (2) for ventricular septal rupture, and 73.3% (11) for papillary muscle rupture. These mechanical complications occurred at a median of 23.5 hours (interquartile range 5.0 to 76.8) after symptom onset and were associated with 44% (23 of 52) survival through 90 days, which accounted for 11% of the 90-day mortality. Factors associated with mechanical complications were older age, female gender, Q waves, presence of radiologic pulmonary edema, and increased prerandomization troponin levels. In conclusion, rates of mechanical complications are lower with primary PCI than those previously reported after fibrinolytic therapy.