Ventricular septal rupture after acute myocardial infarction

Delayed ventricular septal rupture complicated with ventricular aneurysm in a case of myocardial infarction with non-obstructive coronary arteries

BACKGROUND

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare cause of heart attack, which may not receive sufficient attention from patients during post-discharge treatment, especially among those with normal coronary angiography results.

CASE PRESENTATION

We present the case of a 65-year-old woman who was readmitted to the hospital with ventricular septal rupture (VSR) complicated by ventricular aneurysm, occurring 2 weeks after myocardial infarction. During the initial admission, coronary angiography revealed normal coronary arteries, leading to a diagnosis of MINOCA. Epicardial coronary vasospasm or coronary embolism was considered as potential causes; however, the patient did not adhere to standardized treatment upon initial discharge. The delayed VSR led to a decline in cardiac function but did not result in severe hemodynamic impairment. Following correction of heart failure with medications, the patient underwent percutaneous VSR repair 19 days after diagnosis and was discharged with a favorable recovery.

CONCLUSIONS

The occurrence of delayed VSR complicated with ventricular aneurysm in patients with MINOCA is rare, highlighting the possibility of serious complications in MINOCA cases. Both cardioprotective therapies and cause-targeted therapies are essential in the management of patients with MINOCA.

Ventricular septal defect complicating acute myocardial infarction: diagnosis and management. A Clinical Consensus Statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the ESC Working Group on Cardiovascular Surgery

Ventricular septal defects are a rare complication after acute myocardial infarction with a mortality close to 100% if left untreated. However, even surgical or interventional closure is associated with a very high mortality and currently no randomized controlled trials are available addressing the optimal treatment strategy of this disease. This state-of-the-art review and clinical consensus statement will outline the diagnosis, hemodynamic consequences and treatment strategies of ventricular septal defects complicating acute myocardial infarction with a focus on current available evidence and a focus on major research questions to fill the gap in evidence.

Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.

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.

Time course of cardiac rupture after acute myocardial infarction and comparison of clinical features of different rupture types

Objective

This study aimed to investigate the time course of cardiac rupture (CR) after acute myocardial infarction (AMI) and the differences among different rupture types.

Method

We retrospectively analyzed 145 patients with CR after AMI at Shanxi Cardiovascular Hospital from June 2016 to September 2022. Firstly, according to the time from onset of chest pain to CR, the patients were divided into early CR (≤24 h) (n = 61 patients) and late CR (>24 h) (n = 75 patients) to explore the difference between early CR and late CR. Secondly, according to the type of CR, the patients were divided into free wall rupture (FWR) (n = 55) and ventricular septal rupture (VSR) (n = 90) to explore the difference between FWR and VSR.

Results

Multivariate logistic regression analysis showed that high white blood cell count (OR = 1.134, 95% CI: 1.019-1.260, P = 0.021), low creatinine (OR = 0.991, 95% CI: 0.982-0.999, P = 0.026) were independently associated with early CR. In addition, rapid heart rate (OR = 1.035, 95% CI: 1.009-1.061, P = 0.009), low systolic blood pressure (OR = 0.981, 95% CI: 0.962-1.000, P = 0.048), and anterior myocardial infarction (OR = 5.989, 95% CI: 1.978-18.136, P = 0.002) were independently associated with VSR.

Conclusion

In patients with CR, high white blood cell count and low creatinine were independently associated with early CR, rapid heart rate, low systolic blood pressure, and anterior myocardial infarction were independently associated with VSR.

Post-infarction ventricular septal rupture complicated with cardiogenic shock and multiple organ hemorrhage: An autopsy case report

Ventricular septal rupture (VSR) is a catastrophic mechanical complication of acute myocardial infarction (AMI) that can result in acute heart failure. Delaying operative intervention frequently leads to cardiogenic shock and multi-organ failure. Here we report a case of massive anterior MI complicated with VSR that was discovered through cardiac Doppler ultrasound and suspected multiple organ hemorrhage. The patient showed signs of rapid cardiogenic shock and eventually died. The morphological changes of VSR and MI were identified during necropsy, and microscopic examinations of the heart, brain, and kidney revealed multiple organ hemorrhage. This autopsy case suggested that the complication of VSR caused by AMI results in a reduction of oxygen and nutrient content of the circulating blood throughout the body and, eventually, functional failure of multiple organs. We provide clinical and pathological evidence elucidating changes in multiple organs under the severe condition of post-infarction VSR and demonstrate the consequences of a lack of immediate surgery and sufficient medical intervention for a patient suffering from AMI with VSR.

Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report

BACKGROUND

The current guidelines have discouraged the routine use of intra-aortic balloon pump (IABP) in cardiogenic shock complicating acute coronary syndrome (ACS). Since then, the trend of IABP utilization in ACS has been declining. Nevertheless, the guidelines still preserve the recommendation of IABP use in hemodynamic instability or cardiogenic shock caused by post myocardial infarction (MI) ventricular septal rupture (VSR).

CASE PRESENTATION

A 46-years-old diabetic Southeast Asian female was referred from a peripheral facility with intractable heart failure despite treatment with vasoactive agents and diuretics for five days. The ECG suggested a recent anteroseptal myocardial infarction with normal high-sensitivity troponin-I value. The echocardiography detected a regional wall motion abnormality and a 10 mm wide ventricular septal defect. Invasive coronary angiography revealed a severe two-vessel coronary artery disease. We planned a delayed surgical strategy with preoperative optimization using IABP as a bridge to surgery. IABP implantation followed by significant hemodynamic improvement and rapid resolution of heart failure without any inotrope support. Afterwards, coronary artery bypass grafting (CABG) and VSR surgical repair were performed. We safely removed IABP on the third postoperative day with proper weaning and minimal vasoactive support.

CONCLUSION

We report a case where IABP still provided benefits for a patient with intractable heart failure caused by undetermined onset MI complicated by VSR. The use of IABP in such a case is in accordance with the recommendation of the current guidelines. Several studies showed that IABP use during preoperative optimization in the case of post-MI VSR was associated with survival benefits.

Sex differences in trends and outcomes of acute myocardial infarction with mechanical complications in the United States

BACKGROUND

Mechanical complications (MC) are rare but significant sequelae of acute myocardial infarction (AMI). Current data on sex differences in AMI with MC is limited.

METHODS

We queried the National Inpatient Sample database to identify adult patients with the primary diagnosis of AMI and MC. The main outcome of interest was sex difference in-hospital mortality. Secondary outcomes were sex differences in the incidence of acute kidney injury (AKI), major bleeding, use of inotropes, permanent pacemaker implantation (PPMI), performance of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), surgery (VSD repair and MV surgery), pericardiocentesis, use of mechanical circulatory support (MCS), ischemic stroke, and mechanical ventilation.

RESULTS

Among AMI-MC cohort, in-hospital mortality was higher among females compared to males (41.24% vs 28.13%: aOR 1.39. 95% CI 1.079-1.798; p = 0.01). Among those who had VSD, females also had higher in-hospital mortality compared to males (56.7% vs 43.1%: aOR 1.74, 95% CI 1.12-2.69; p = 0.01). Females were less likely to receive CABG compared to males (12.03% vs 20%: aOR 0.49 95% CI 0.345-0.690; p < 0.001).

CONCLUSION

Despite the decreasing trend in AMI admission, females had higher risk of MC and associated mortality. Significant sex disparities still exist in AMI treatment.

Perioperative Challenges and Outcome After Surgical Correction of Post-myocardial Infarction Ventricular Septal Rupture: A Retrospective Single Center Study

BACKGROUND

Ventricular septal rupture (VSR) is a rare but grave complication of acute myocardial infarction (AMI). It is a mechanical complication of myocardial infarction where patients may present either in a compensated state or in cardiogenic shock. The aim of the study is to determine the in-hospital mortality. The study also aims to identify the predictors of outcomes (in-hospital mortality, vasoactive inotrope score (VIS), duration of ICU stay and mechanical ventilation in the postoperative period) and compare the clinical and surgical parameters between survivors and non-survivors.

METHODS

This is a retrospective study. The data of 90 patients was collected from the medical records and the data comprising of 13 patients who underwent VSR closure by single patch technique, or septal occluder, and those who expired before receiving the treatment, was excluded. The data of 77 patients diagnosed with post-AMI VSR and who underwent surgical closure of VSR by double patch technique was included in this study. Clinical findings and echocardiography parameters were recorded from the perioperative period. The statistical software used was SPSS version 27. The primary outcome was determining the in-hospital mortality. The secondary outcome was identifying the clinical parameters that are significantly more in the non-survivors, and the factors predicting the in-hopsital mortality and morbidity (increased duration of ICU stay, and of mechanical ventilation, postoperative requirement of high doses of vasopressors and inotropes). Subgroup analysis was done to identify the relation of various clinical parameters with the postoperative complications. The factors predicting the in-hospital mortality were illustrated by a forest plot.

RESULTS

The mean age of the patients was 60.35 (±9.9) years, 56 (72.7%) were males, and 21 (27.3%) were females. Requirement of mechanical ventilation preoperatively (OR 3.92 [CI 2.91-6.96]), cardiogenic shock at presentation (OR 4 [CI 2.33 - 6.85]), requirement of IABP (OR 2.05 [CI 1.38-3.94]), were predictors of mortality. The apical location of VSR had been favorable for survival. The EUROScore II at presentation correlated with the postoperative VIS (level of significance [LS] 0.0011, R 0.36. The in-hospital mortality in this study was 33.76%.

CONCLUSION

The in-hospital mortality of VSR is 33.76%. Cardiogenic shock at presentation, non-apical site of VSR, preoperative requirement of mechanical ventilation, high VIS preoperatively, perioperative utilization of IABP, prolonged CPB time, postoperative duration of mechanical ventilation, and high postoperative VIS were the factors associated with increased odds of in-hospital mortality.

Echocardiographic features of myocardial rupture after acute myocardial infarction on emergency echocardiography

OBJECTIVE

Myocardial rupture is a fatal complication of acute myocardial infarction (AMI). Early diagnosis of myocardial rupture is feasible when emergency physicians (EPs) perform emergency transthoracic echocardiography (TTE). The purpose of this study was to report the echocardiographic features of myocardial rupture on emergency TTE performed by EPs in the emergency department (ED).

METHODS

This was a retrospective and observational study involving consecutive adult patients presenting with AMI who underwent TTE performed by EPs in the ED of a single academic medical center from March 2008 to December 2019.

RESULTS

Fifteen patients with myocardial rupture, including eight (53.3%) with free wall rupture (FWR), five (33.3%) with ventricular septal rupture (VSR), and two (13.3%) with FWR and VSR, were identified. Fourteen of the 15 patients (93.3%) were diagnosed on TTE performed by EPs. Diagnostic echocardiographic features were found in 100% of the patients with myocardial rupture, including pericardial effusion for FWR and a visible shunt on the interventricular septum for VSR. Additional echocardiographic features indicating myocardial rupture were thinning or aneurysmal dilatation in 10 patients (66.7%), undermined myocardium in six patients (40.0%), abnormal regional motions in six patients (40.0%), and pericardial hematoma in six patients (40.0%).

CONCLUSION

Early diagnosis of myocardial rupture after AMI is possible using echocardiographic features on emergency TTE performed by EPs.

Role of echocardiography in the management of ventricular septal rupture after acute myocardial infarction

Ventricular septal rupture (VSR) is a rare and devastating complication of acute myocardial infarction. Early detection, assessment of the hemodynamic impact, and illustration of the pathophysiological context are crucial functions of echocardiography in decision-making for intensive management and reparative intervention. To evaluate this entity, echocardiography exhibits two strengths: its bedside nature and its multiple modalities. This document reviews the comprehensive use of echocardiography in the study of post-infarction VSR.

Enzyme-Responsive Nanoparticles for the Targeted Delivery of an MMP Inhibitor to Acute Myocardial Infarction

Herein, we have developed a drug-loaded matrix metalloproteinase (MMP)-responsive micellar nanoparticle (NP) intended for minimally invasive intravenous injection during the acute phase of myocardial infarction (MI) and prolonged retention in the heart for small-molecule drug delivery. Peptide-polymer amphiphiles (PPAs) bearing a small-molecule MMP inhibitor (MMPi), PD166793, were synthesized via ring-opening metathesis polymerization (ROMP) and formulated into spherical micelles by transitioning to aqueous solution. The resulting micellar NPs underwent MMP-induced aggregation, demonstrating enzyme responsiveness. Using a rat MI model, we observed that these NPs were capable of successfully extravasating into the infarcted region of the heart where they were retained due to the active, enzyme-mediated targeting, remaining detectable after 1 week post administration without increasing macrophage recruitment. Furthermore, in vitro studies show that these NPs demonstrated successful drug release following MMP treatment and maintained drug bioactivity as evidenced by comparable MMP inhibition to free MMPi. This work establishes a targeted NP platform for delivering small-molecule therapeutics to the heart after MI, opening possibilities for myocardial infarction treatment.

Extracorporeal Left Ventricular Assist Device as a Bridge to Surgery for Ventricular Septal Rupture After Acute Myocardial Infarction

Ventricular septal rupture (VSR) after acute myocardial infarction (AMI) is a rare but often fatal complication. Surgery is considered the preferred treatment, although the optimal timing is discussed. The immediate preoperative hemodynamic status significantly impacts postoperative outcomes, making mechanical circulatory support (MCS) devices crucial for perioperative hemodynamic stability. We present the case of a 61-year-old woman with no remarkable cardiological history admitted to our hospital with a diagnosis of AMI and VSR. Due to hemodynamic instability and cardiogenic shock, we utilized an intra-aortic balloon pump (IABP) and an extracorporeal left ventricular assist device (extra-VAD) as a bridge to surgery. After 17 days of IABP support, the patient experienced hemodynamic instability, elevated lactate levels, pulmonary edema, and eventually bedside endotracheal infiltration inventor-assisted breathing. Subsequently, the IABP was removed, and the patient underwent 6 days of extra-VAD therapy, resulting in hemodynamic stability, a decline in lactate levels, and a reduction in pulmonary edema on X-ray. Surgical coronary artery bypass grafting and VSR repair were successfully performed without periprocedural complications, and the patient was subsequently discharged. Extra-VAD is useful for serious cardiogenic shock in patients with VSR after AMI and may be considered a reasonable approach as a bridge to surgery.

Analysis of immortal-time effect in post-infarction ventricular septal defect

Introduction

Time-fixed analyses have traditionally been utilized to examine outcomes in post-infarction ventricular septal defect (VSD). The aims of this study were to: (1) analyze the relationship between VSD closure/non-closure and mortality; (2) assess the presence of immortal-time bias.

Material and methods

In this retrospective cohort study, patients with ST-elevation myocardial infarction (STEMI) complicated by VSD. Time-fixed and time-dependent Cox regression methodologies were employed.

Results

The study included 80 patients: surgical closure (n = 26), transcatheter closure (n = 20), or conservative management alone (n = 34). At presentation, patients without VSD closure exhibited high-risk clinical characteristics, had the shortest median time intervals from STEMI onset to VSD development (4.0, 4.0, and 2.0 days, respectively; P = 0.03) and from STEMI symptom onset to hospital arrival (6.0, 5.0, and 0.8 days, respectively; P < 0.0001). The median time from STEMI onset to closure was 22.0 days (P = 0.14). In-hospital mortality rate was higher among patients who did not undergo defect closure (50%, 35%, and 88.2%, respectively; P < 0.0001). Closure of the defect using a fixed-time method was associated with lower in-hospital mortality (HR = 0.13, 95% CI 0.05-0.31, P < 0.0001, and HR 0.13, 95% CI 0.04-0.36, P < 0.0001, for surgery and transcatheter closure, respectively). However, when employing a time-varying method, this association was not observed (HR = 0.95, 95% CI 0.45-1.98, P = 0.90, and HR 0.88, 95% CI 0.41-1.87, P = 0.74, for surgery and transcatheter closure, respectively). These findings suggest the presence of an immortal-time bias.

Conclusions

This study highlights that using a fixed-time analytic approach in post-infarction VSD can result in immortal-time bias. Researchers should consider employing time-dependent methodologies.

[Right ventricle free wall rupture during transcatheter occluder implantation in a patient with postinfarction rupture of the interventricular septum and COVID-19-associated myocarditis. Case report]

Intraventricular septum rupture is a rare mechanic complication of myocardial infarction associated with high mortality. This case describes STEMI in recovered patient after COVID 19 associated pneumonia, which was complicated by ventricular septum rupture followed by cardiogenic shock. It was managed by percutaneous occluder implantation. The procedure was complicated by right ventricular wall rupture. Postmortem examination of myocardium showed the signs of inflammation infiltrate and myocyte necrosis, according to histopathological Dallas criteria diagnosis of COVID-19 associated myocarditis was established. The COVID-19 pandemic has contributed to increasing cardiovascular mortality. This is typically attributed to diminishing resources for timely and appropriate medical care, and patients' late presentations for fear of contracting the infection. Cardiovascular complication of COVID-19 may be another contributing factor. Further research is needed to improve our understanding of the mechanisms and long-term sequelae of myocardium damage in COVID-19, to optimize treatment strategy and subsequent follow-up in such patients.

Clinical assessment of VSR site and size and its relation to the severity of heart failure in post-myocardial infarction ventricular septal rupture patients

BACKGROUND

Ventricular septal rupture (VSR) is a rare but well-known mechanical consequence of an acute myocardial infarction (AMI). Even in the later stages of re-perfusion therapy, the result of VSR remains poor. Our aim is to assess the site and size of VSR in relation to the severity of cardiac failure.

METHODS

From January 2016 to December 2022, a total of 71 patients with a diagnosis of post-myocardial infarction VSR were admitted to the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China. Data records were retrospectively included in this registry. In all patients, clinical and echocardiographic data were gathered, and statistical analyses were performed.

RESULTS

A total of 71 consecutive patients (mean age: 66.27 ± 8.88 years); 50.7% male, 49.3% female, with (M:F) ratio of almost (1:1). Left ventricular ejection fraction (LVEF) was (48.55 ± 10.44%) on echocardiography, and apical VSR was the most common site (69.0%). Overall, the VSD site was strongly related to the VSD size (p = .016), LVEF (p = .012), AMI site (p = .001), and affected coronary vessel (p = .004). Prodromal angina (p = .041), intra-aortic balloon pump (p = .002), affected coronary vessels (p = .020), pro-BNP (p = .000), and LVEF (p = .017) were predictors of the severity of heart failure.

CONCLUSIONS

Diabetes mellitus is a common risk factor for post-myocardial infarction VSR. VSR site and size had no relation to the severity of heart failure. A presentation with prodromal angina predicted severe heart failure and a worse prognosis.

Ventricular Septal Rupture Management in Patients With Acute Myocardial Infarction: A Review

Untreated myocardial infarction (MI) can potentially lead to many fatal complications which require immediate management. One of them is ventricular septal rupture (VSR) which necessitates the hemodynamic stabilization and closure of the septal rupture. Conventional treatment strategy involves surgical repair; however, percutaneous transcatheter repair using an occluder device is a promising upcoming approach. We conducted a detailed review of various published articles and examined the trends in incidence, risk factors, and pathophysiology of MI leading to VSR followed by an in-depth analysis of the various management strategies for the same. In the current clinical scenario, thrombolysis is an imperative management strategy that has been shown to decrease the occurrence of VSR by manifolds, more specifically in patients having ST-elevated MI. Delayed surgical closure remains the main treatment for post-infarction VSR. Other newer modalities, such as percutaneous closure devices and mechanical circulatory supports, are attractive alternative or complementary strategies to treat such patients, both postoperatively and perioperatively. However, earlier surgical repair in VSR increases the risk of mortality, and the optimal timing for VSR closure remains controversial. Despite surgical closure of VSR being the traditional treatment, it presents a considerably high operative risk. Although newer interventions such as percutaneous closure devices and mechanical circulatory supports provide impressive outcomes, their efficacy in high-risk patients remains inconclusive.

Early surgical outcomes of a modified infarct exclusion technique in acute post-myocardial infarction ventricular septal rupture: a single-centre experience

Introduction

Operative mortality in an acute post-myocardial infarction (AMI) ventricular septal rupture (VSR) is high. In addition to ventricular dysfunction, friable myocardium adds to the technical difficulty of the operation. In a modified infarct exclusion technique, the right ventricle is left undisturbed and the free edge of the pericardial patch is incorporated in the sutures while closing the left ventriculotomy. This simplifies the procedure and decreases the chances of right ventricular dysfunction, any residual defect, and bleeding.

Methods

Study design

A retrospective analysis of patients with VSR following AMI operated in our institute from January 2018 to June 2021 was done.

Results

Over the last 3 years, 16 patients with AMI VSR were treated with a modified infarct exclusion technique. Eight patients presented in cardiogenic shock preoperatively and were put on intra-aortic balloon pump support. All patients could be weaned successfully from the cardiopulmonary bypass, no patient had any residual defect, and none of the patients required re-exploration for bleeding. Postoperatively, 5 patients died within the first week and 2 more patients subsequently died due to intractable arrhythmias over the next 30 days.

Conclusions

In our centre, the mortality following repair of VSR after AMI was 43%. The modified infarct exclusion technique is a good technique with less chances of postoperative re-exploration and residual defect.

Clinical characteristics, prognostic factors, and outcomes of ventricular septal rupture in patients with acute myocardial infarction

Ventricular septal rupture (VSR) is a rare but devastating complication in patients with acute myocardial infarction (AMI). This was a retrospective single-center observational study which aimed to assess the characteristics and outcomes of VSR patients and identify risk factors for in-hospital mortality of VSR patients in the era of percutaneous intervention. Patients with VSR after AMI at the First Affiliated Hospital of Xi'an Jiaotong University from January 2016 to December 2020 were enrolled. Among 5395 consecutive patients with AMI, 42 patients (0.78%) were diagnosed with VSR. Left anterior descending coronary artery was the culprit vessel in most cases (84.4%, 27/32). In the multivariate analysis, female sex (odds ratio (OR): 14.043, 95% confidence interval (CI): 1.396-141.283, p = 0.025) and lower platelet count on admission (OR: 0.979; 95% CI: 0.963-0.995; p = 0.009) were significant risk factors of in-hospital death in VSR patients. In all, 11 patients (26.2%) underwent surgical repair, and the rest were treated medically. The 1-year mortality was lower in the surgical group (36.4%, 4/11) than that in the conservative group (74.2%, 23/31) (p = 0.034). During the follow-up, VSR patients treated surgically tended to have a higher long-term survival rate than those treated medically (log rank χ² = 5.005, p = 0.025). The prognosis of patients with VSR remained poor in this study. Female sex and lower platelet count were independent risk factors of in-hospital death in VSR patients. The long-term survival rate of patients treated with surgical repair was significantly better than that of patients treated conservatively.

Real-Time Three-Dimensional Transthoracic Echocardiography as a Decision-Making Tool for the Management of Postmyocardial Infarction Ventricular Septal Rupture: Guiding the Percutaneous Transcatheter Closure

Postmyocardial infarction ventricular septal rupture (PI-VSR) is a rare but lethal complication of acute myocardial infarction (AMI). The diagnosis and management of AMI remain challenging. When VSR is suspected, transthoracic and/or transesophageal echocardiography at patient's bedside is a test of choice for early diagnosis and therapeutical guidance. We aim to discuss the management of patients with VSR due to AMI with the focus on transcatheter closure management guided by real-time three-dimensional (RT3D) transthoracic echocardiography (TTE). A 64-year-old male patient was diagnosed with recent anterolateral ST elevation myocardial infarction and complication intra VSR as its complication. After remeasurement of the defect by TTE, we found an 8-11 mm defect in VSR. We performed transcatheter closure for VSR guided by RT3D TTE using Septal Occluder device No. 14. Evaluation after the procedure by TTE revealed that the device was well-seated. Percutaneous closure of PI-VSR may be considered in hemodynamically unstable patients if the risk of surgery is deemed to be too high or the anatomy is amenable to device insertion. RT3D echocardiography allows better delineation of the size and shape of the rupture, while serves as a guide during percutaneous transcatheter PI-VSR closure.

Intraoperative ventricular septal rupture: A case report

Ventricular septal rupture (VSR) is a rare complication of myocardial infarction that requires surgical repair. Herein, we describe a case of intraoperative VSR requiring patch repair and postoperative extracorporeal membrane oxygenation (ECMO) support. This case highlights the risk factors, patient presentation, and management recommendations for this potentially lethal pathology.

Management and outcomes of ventricular septal defects after acute myocardial infarction: A multicenter retrospective study

BACKGROUND AND AIM

The mortality rate of patients with post-myocardial infarction (MI) ventricular septal defects (VSDs) is high, and the benefit of surgery is unclear. We aimed to investigate the management and outcomes of post-MI VSD over a 10-year period in a large cohort.

METHODS

Data of patients with post-MI VSD admitted in three French university hospitals from 2008 to 2019 were examined. The characteristics of those who underwent surgery were compared with those who received medical treatment. Mortality risk factors, survival curves, and outcomes at 30 days and 1 year after treatment were determined.

RESULTS

Of the 92 patients whose data were examined, 50 underwent surgery and 42 received exclusive medical treatment. All patients were critically ill. Overall, 76.1% of patients received inotropic support, and 63% received mechanical ventilation. Circulatory assistance, mainly via intra-aortic balloon pump and extra-corporeal membrane oxygenation, was provided to 46.7% patients, with 14.1% requiring a second assistance. The median time to surgery was 4 days. At 1 year, mortality was 46% in those who underwent surgery and 83.3% in those treated medically (p < .001). Survival curves at 1 and 3 months showed major differences, and the survival rate showed little change 30 days after treatment. Cardiogenic shock and cardiac arrest emerged as risk factors for mortality.

CONCLUSIONS

In our retrospective, multicenter study, the mortality resulting from post-MI VSD did not seem to improve over the last decade. Although surgery carried considerable risks, it improved survival.

Overview of Mechanical Circulatory Support for the Management of Post-Myocardial Infarction Ventricular Septal Rupture

Post-myocardial infarction ventricular septal rupture (PIVSR) is becoming increasingly rare in the percutaneous coronary intervention era; however, the mortality rates remain high. Surgical repair is the gold standard treatment for PIVSR but is associated with surgical difficulty and high mortality. Therefore, the timing of surgery is controversial (i.e. either undertake emergency surgery or wait for resolution of organ failure and scarring of the infarcted area). Although long-term medical management is usually ineffective, several mechanical circulatory support (MCS) devices have been used to postpone surgery to an optimal timing. Recently, in addition to venous arterial extracorporeal membrane oxygenation (VA-ECMO), new MCS devices, such as Impella (Abiomed Inc., Boston, MA, USA), have been developed. Impella is a pump catheter that pumps blood directly from the left ventricle, in a progressive fashion, into the ascending aorta. VA-ECMO is a temporary MCS system that provides complete and rapid cardiopulmonary support, with concurrent hemodynamic support and gas exchange. When left and right heart failure and/or respiratory failure occur in cardiogenic shock or PIVSR after acute myocardial infarction, ECpella (Impella and VA-ECMO) is often introduced, as it can provide circulatory and respiratory assistance in a shorter period. This review outlines the basic concepts of MCS in PIVSR treatment strategies and its role as a bridge device, and discusses the efficacy and complications of ECpella therapy and the timing of surgery.

Analysis of influencing factors for prognosis of patients with ventricular septal perforation: A single-center retrospective study

Background

Ventricular septal rupture (VSR) is a type of cardiac rupture, usually complicated by acute myocardial infarction (AMI), with a high mortality rate and often poor prognosis. The aim of our study was to investigate the factors influencing the long-term prognosis of patients with VSR from different aspects, comparing the evaluation performance of the Gensini score, Sequential Organ Failure Assessment (SOFA) score and European Heart Surgery Risk Assessment System II (EuroSCORE II) score systems.

Methods

This study retrospectively enrolled 188 patients with VSR between Dec 9, 2011 and Nov 21, 2021at the First Affiliated Hospital of Zhengzhou University. All patients were followed up until Jan 27, 2022 for clinical data, angiographic characteristics, echocardiogram outcomes, intraoperative, postoperative characteristics and major adverse cardiac events (MACEs) (30-day mortality, cardiac readmission). Cox proportional hazard regression analysis was used to explore the predictors of long-term mortality.

Results

The median age of 188 VSR patients was 66.2 ± 9.1 years and 97 (51.6%) were males, and there were 103 (54.8%) patients in the medication group, 34 (18.1%) patients in the percutaneous transcatheter closure (TCC) group, and 51 (27.1%) patients in the surgical repair group. The average follow-up time was 857.4 days. The long-term mortality of the medically managed group, the percutaneous TCC group, and the surgical repair group was 94.2, 32.4, and 35.3%, respectively. Whether combined with cardiogenic shock (OR 0.023, 95% CI 0.001-0.054, P = 0.019), NT-pro BNP level (OR 0.027, 95% CI 0.002-0.34, P = 0.005), EuroSCORE II (OR 0.530, 95% CI 0.305-0.918, P = 0.024) and therapy group (OR 3.518, 95% CI 1.079-11.463, P = 0.037) were independently associated with long-term mortality in patients with VSR, and this seems to be independent of the therapy group. The mortality rate of surgical repair after 2 weeks of VSR was much lower than within 2 weeks (P = 0.025). The cut-off point of EuroSCORE II was determined to be 14, and there were statistically significant differences between the EuroSCORE II < 14 group and EuroSCORE II≥14 group (HR = 0.2596, 95%CI: 0.1800-0.3744, Logrank P < 0.001).

Conclusion

Patients with AMI combined with VSR have a poor prognosis if not treated surgically, surgical repair after 2 weeks of VSR is a better time. In addition, EuroSCORE II can be used as a scoring system to assess the prognosis of patients with VSR.

Acute Ischaemic Mitral Valve Regurgitation

Acute ischaemic mitral regurgitation (IMR) is an increasingly rare and challenging complication following acute myocardial infarction. Despite recent technical advances in both surgical and percutaneous interventions, a poor prognosis is often associated with this challenging patient cohort. In this review, we revisit the diagnosis and typical echocardiographic features, and evaluate current surgical and percutaneous treatment options for patients with acute IMR.

Inferior ST-Segment Elevation Can Predict In-Hospital Mortality in Patients with Anterior Myocardial Infarction Complicated by Ventricular Septal Rupture

Background

Electrocardiogram (ECG) findings in patients with anterior wall myocardial infarction (MI) complicated by ventricular septal rupture (VSR) have rarely been studied.

Methods

We conducted a single-center retrospective study among patients with anterior MI complicated by VSR over the past ten years. The presence of ST-segment elevation (STE) in inferior leads and new onset of complete right bundle branch block (RBBB) on ECG were studied for the prediction of in-hospital mortality.

Results

Among the 85 patients enrolled, 45 (52.9%) were male, with a median age of 70 years. Sixty-five patients (76.5%) died in the hospital, and the remaining 20 patients (23.5%) had improved conditions and were discharged. Inferior STE was present in 35 patients (41.2%), including 32 patients in the death group and 3 patients in the survival group (P = 0.005). New-onset RBBB was present in 25 patients (29.4%), with 22 patients in the death group and 3 patients in the survival group (P = 0.103). Multivariate logistic regression showed that inferior STE was an independent predictor of in-hospital death in patients with anterior MI and VSR (OR: 14.488; 95% CI: 1.708-122.887; P = 0.014).

Conclusions

In patients with anterior MI complicated by VSR, inferior STE was associated with a higher risk of in-hospital mortality.

The evaluation of levosimendan in patients with acute myocardial infarction related ventricular septal rupture undergoing cardiac surgery: a prospective observational cohort study with propensity score analysis

STUDY OBJECTIVE

The purpose of the present study was to evaluate the efficacy of levosimendan in patients with acute myocardial infarction related ventricular septal rupture (AMI-VSR) underwent cardiac surgery.

DESIGN

Prospective observational cohort study with propensity score analysis.

PATIENTS

There were 261 patients with AMI-VSR in our study. After 1:1 propensity matching, 106 patients (53 levosimendan and 53 control) were selected in the matched cohort.

INTERVENTIONS

None.

MEASUREMENTS

Patients who received levosimendan were assigned to the levosimendan group (n = 164). The patients who were not received were levosimendan assigned to the control group (n = 97). The levosimendan was initiated immediately after cardiopulmonary bypass. Then, it has been maintained during the postoperative 3 days. The poor outcomes were identified as follows: death and postoperative complications (postoperative stroke, low cardiac output syndromeneeded mechanical circulatory support after surgery, acute kidney injury (≥ stage III), postoperative infection or septic shock, new developed atrial fibrillation or ventricular arrhythmias).

MAIN RESULTS

Before matching, the control group had more length of ICU stay (6.69 ± 3.90 d vs. 5.20 ± 2.24 d, p < 0.001) and longer mechanical ventilation time (23 h, IQR: 16-53 h vs. 16 h, IQR: 11-23 h, p < 0.001). Other postoperative outcomes have not shown significant differences between two groups. After matching, no significant difference was found between both groups for all postoperative outcomes. The Kaplan-Meier survivul estimate and log-rank test showed that the 90-day survival had no significant differences between two groups before and after matching.

CONCLUSION

Our study found that a low-dose infusion of levosimendan in AMI-VSR patients underwent surgical repair did not associated with positively affect to postoperative outcomes.

Ventricular septal rupture: insights into an old disease

Ventricular septal rupture (VSR) is a serious complication of ST-elevation myocardial infarction (STEMI) and surgery is the reference treatment. We aimed at describing trends in management and mortality during the last four decades and reporting mortality predictors in these patients. We conducted a single-center retrospective study of patients sustaining a VSR from 1981 to 2020. We screened 274 patients and included 265 for analysis. The number of patients decreased over the years: 80, 88, 56, and 50 in each 10-year time span. In-hospital mortality decreased significantly since 1990 (logrank 0.007). The median age was 72.0 years IQR [66-78] and 188 patients (70.9%) were operated on. IABP was used more routinely (p < 0.0001). In-hospital mortality was assessed at 66.8% (177 patients) and main predictors of death were a time from MI to surgery < 8 days HR 2.7 IC95% [1.9-3.8] p < 0.0001, a Killip class > 2 HR 2.5 IC [1.9-3.4] p < 0.0001 and Euroscore 2 > 20 HR 2.4 IC [1.8-3.2] p < 0.0001. A "time from MI to surgery" of 8 days offers the best ability to discriminate between patients with or without mortality. The ability of "Euroscore 2 and Killip" to detect the patients most likely to wait 8 days for surgery was at 0.81 [0.73-0.89] p < 0.0001. Mortality remains high over the years. Euroscore 2, Killip class, and time from MI to surgery are the main mortality predictors. Patients with a Killip < 3 and a Euroscore < 20 should be monitored at least 8 days since MI before being referred to surgery.

Post Myocardial Infarction Ventricular Septal Rupture Revealed By Acute Liver Failure Symptoms: A Case Report

Introduction:

The mechanical complications of acute myocardial infarction (AMI) still kill despite the evolution of medicine. Early diagnosis and adequate management are necessary to improve the prognosis, and this requires first, a good clinical examination that should raise the suspicion of a mechanical complication, then the echocardiography is performed to confirm the diagnosis.

Case Presentation:

We present a case of a 64-year-old patient admitted to the emergency room for jaundice with delayed ST-segment elevation myocardial infarction (STEMI). Physical examination revealed signs of right heart failure, which led us to associate jaundice with signs of acute liver failure secondary to right heart failure. Echocardiography confirmed the diagnosis of a ventricular septal rupture (VSR) with left-right shunt, and a significant dilation of the right ventricle. The patient underwent surgical closure of the VSR with fatal evolution.

Discussion:

VSR is a rare life-threatening mechanical complication of AMI. The clinical signs depend on the left-right shunt and the onset of heart failure, which are 2 major determinants of the therapeutic strategy and the timing of the surgery. Despite surgical closure of the VSR, the mortality remains high, but the prognosis is better in patients treated with surgery than in patients who are treated medically only.

Conclusion:

The clinical presentation of VSR may differ from a patient to another. Good clinical sense and echocardiography are essential to set early diagnosis, and thus decide on the adequate management at the right time.

An Undiagnosed Ventricular Septal Rupture Presenting as New Onset Heart Failure: A Rare Complication of an Anterior Myocardial Infarction

Ventricular septal ruptures (VSR) are a rare but fatal complication of acute myocardial infarctions. We present a patient complaining of new onset heart failure symptoms that were found to be secondary to a new ventricular septal rupture from a recently undiagnosed anterior myocardial infarction. The patient underwent successful VSR patch repair with eventual recovery. This case highlights the importance of early diagnosis of VSR and reviews management options and appropriate timing for intervention.

Indicators and predictors of in-hospital mortality and survival in patients with ventricular septal rupture

Background

Ventricular septal rupture (VSR), a mechanical complication of myocardial infarction (MI), usually presents with rapid clinical deterioration with acute heart failure or cardiogenic shock. VSR may occur within 24 h to several days after MI and can occur in both anterior and inferior wall MI. Although guidelines recommend emergent surgery, this is associated with a high mortality rate of up to 40%. Intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) stabilize patients in preparation for angiography and surgery. Delayed surgery allows better septal repair in scarring tissue but also carries the risk of rupture extension and death while waiting. Percutaneous closure of the defect with appropriately designed devices results in better survival in the subacute phase.

Aims

To study the indicators and predictors of VSR in the current era of primary percutaneous coronary interventions and mechanical circulatory support.

Methods

Of total of 34,681 patients presenting with MI, the incidence of VSR was 0.45%. We sought to evaluate the predictors of survival and death in VSR. Coronary angiography (CAG) was performed, hemodynamic support provided to unstable patients, and consenting patients were referred to definitive therapy, either surgery or percutaneous device closure. The previously postulated hypotheses of triple vessel disease (TVD), diabetes mellitus (DM), and concentric left ventricular hypertrophy (LVH) due to Hypertension (HTN) being protective against VSR were explored.

Results

Of the 169 patients with VSR, we found that the group that survived was mostly men and the mean age was 61.5 years; this was in contrast to the non-survivors, who were mainly women, and the mean age was 65.2 years (p = 0.025); higher Killip Class was 111-1V (p = 0.001), lower LVEF (p = 0.010), apical VSR and LV aneurysm (p = 0.015 and p = 0.002, respectively) were predictors of death. 48 patients underwent CAG, with single vessel disease (SVD) with lower-grade Rentrop collateral flow being most common in the death group. 25 patients were subjected to definitive therapy with surgical patch closure or percutaneous device closure. The patients who died were older by approximately 7 years. The risk factors for coronary artery disease, such as HTN, diabetes, and smoking, were not statistically different between the two groups.

Conclusion

Prevention of myocardial infarction is more important than managing a VSR, which carries a high mortality despite advanced mechanical support and definitive interventional therapy such as emergent surgery and percutaneous device closure.

Transcatheter closure of ventricular septal rupture with prolonged support of intra-aortic balloon pump after primary PCI: a case report

BACKGROUND

Ventricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases.

CASE PRESENTATION

A 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2-3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction.

CONCLUSIONS

Prolonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.

Complicating Acute Myocardial Infarction. Current Status and Unresolved Targets for Subsequent Research

Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full epicardial and tissue reperfusion but also with a very good immediate and long-term clinical outcome. However, the Achilles heel of MI treatment is its ensemble of complications, such as cardiogenic shock due to severe systolic and/or diastolic dysfunction or MI mechanical complications, including perforation of the left ventricular free wall, papillary muscle rupture with acute mitral regurgitation and ventricular septal rupture. They are associated with an increased or, sometimes, with an extremely high mortality rate, determining the overall mortality in an MI patient population. In this review we summarize the mechanisms of MI complications, current therapeutic management and alternative directions for overcoming their devastating consequences. Moreover, we have sought to indicate gaps in the evidence on current treatments as the potential targets for further clinical research. From the perspective of mortality trends that are not improving, the forthcoming therapeutic management of complicated MI will require an individualized and novel approach based on their thorough pathobiology.

Mechanical complications in ST-elevation myocardial infarction: The impact of pre-hospital delay

AIMS

Mechanical complications (MC) (i.e., free wall rupture (FWR), papillary muscle rupture (PMR) and ventricular septal rupture (VSR)) are rare complications of ST- elevation acute myocardial infarction (STEMI). Incidence of MC according to pre-hospital delay remains unknown. We aimed to determine the rates of MC according to pre-hospital delay.

METHODS

Analysis was conducted on the MODIF registry data. Patients were allocated to four groups according to pre-hospital delay: 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h.

RESULTS

6185 patients with complete data were analyzed. Mean age was 64.1 years old and 75.7% of patients were males. Eighty-three patients (1.34%) presented with MC: 44 (0.71%) experienced a FWR, 17 (0.27%) a PMR, and 22 (0.36%) a VSR. Global rates of MC were 0.82%, 1.43%, 1.24% and 5.07% in the four groups of pre-hospital delays - 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h - respectively (p < 0.001). In-hospital mortality rates were high: 44.2%, 47.1% and 54.6% for FWR, PMR and VSR, respectively. In multivariate analysis, factors independently related to the occurrence of MC were older age, female sex, simultaneous COVID-19 infection, absence of dyslipidemia, initial TIMI flow 0 or 1 in the culprit artery, 36 to 48 h-pre-hospital delay and absence of revascularization by percutaneous coronary intervention (PCI) with stent implantation.

CONCLUSION

The probability of MC in STEMI increases with pre-hospital delay. Mechanical complications of STEMI remain associated with a very poor prognosis.

Myocardial infarction with non obstructive coronary arteries complicated with ventricular septal rupture: A case report and literature review

Ventricular septal rupture represents one of the most serious complications after an acute coronary syndrome. Nowadays this condition is rare due to early revascularization, but is still associated with high mortality rate. In this case report, we present an unusual case of a woman suffering an acute myocardial infarction with normal coronary arteries complicated with a ventricular septal rupture, which required surgical correction.

Clinical Characteristics and Contemporary Prognosis of Ventricular Septal Rupture Complicating Acute Myocardial Infarction: A Single-Center Experience

Objectives: Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). We conducted a retrospective analysis of the clinical characteristics of VSR patients and explored the risk factors for long-term mortality. Methods: In this single-center cohort study, 127 patients diagnosed with post-AMI VSR between May 2012 and April 2019 were included. Demographic, clinical, operative, and outcome data were collected. The 30-day and long-term mortality were outcomes of interest. Cox proportional hazard regression analysis was used to explore the predictors of long-term mortality. Results: The mean age of the VSR cohort was 66.6 ± 8.7 years, 67 (52.8%) were males. Among the 127 patients, 78 patients (61.4%) were medically managed, 31 (24.4%) patients underwent percutaneous transcatheter closure (TCC), and 18 (14.2%) patients received surgical repair. The median follow-up time was 1129 days [interquartile range: 802-2019 days]. The 30-day mortality of the medically managed group, percutaneous TCC group, and surgical management group was 93.6, 22.6, and 11.1%, respectively; and the long-term mortality was 96.2, 25.8, and 22.2%, respectively. VSR repair treatment including surgical management (HR 0.01, 95% CI 0.001-0.09, p < 0.001) and percutaneous TCC (HR 0.09, 95% CI 0.03-0.26, p < 0.001) was associated with a better prognosis, and cardiogenic shock (CS) (HR 9.30, 95% CI 3.38-25.62, p < 0.001) was an independent risk factor of long-term mortality. Conclusions: The prognosis of VSR patients without operative management remains poor, especially in those complicated with CS. Timely and improved surgery treatment is needed for better outcomes in VSR patients.

Concomitant ventricular septal rupture and interventricular septal aneurysm in neglected inferior myocardial infarction misdiagnosed with congenital ventricular septal defect: A case report

This study emphasizes that VSD should not be immediately diagnosed as a congenital disorder; instead, regional wall motion abnormalities in the left ventricle should also be taken into account since it may result from mechanical complications of neglected myocardial infarction.

A case report of unexpected right-to-left shunt under mechanical support for post-infarction ventricular septal defect: evaluation with haemodynamic simulator

Background

Post-myocardial infarction ventricular septal defect (PIVSD) is a complication of acute myocardial infarction with high mortality. A percutaneous left ventricular assist device, Impella, is currently used in maintaining haemodynamic stability in PIVSD.

Case summary

A 65-year-old man was transferred to our hospital for treatment of acute myocardial infarction of the proximal right coronary artery. Percutaneous intervention was performed but haemodynamic instability continued. At 10 days after onset, the patient was diagnosed with PIVSD by echocardiogram. To stabilize haemodynamics, we initiated venoarterial extracorporeal membrane oxygenation (ECMO). Three days after ECMO initiation, pulmonary congestion increased and an echocardiogram revealed closed aortic valve and spontaneous echo contrast at the aortic root. After an Impella 2.5 was inserted for unloading of the left ventricle, the oxygenation level and cardiac function rapidly declined. Unexpectedly, an echocardiogram showed a right-to-left shunt (to-and-fro pattern) via PIVSD. By increasing the ECMO and decreasing Impella flow, the shunt flow changed to left-to-right, and oxygenation level and cardiac function improved. Ten days after ECMO was started, elective surgical repair was successfully performed.

Conclusion

ECPELLA (ECMO + Impella) can offset the adverse effects of isolated ECMO support and reduce the PIVSD shunt flow. However, the risk of right-to-left shunt has not been reported, and ECPELLA caused a right-to-left shunt with deoxygenated systemic perfusion in the present case. A simulation study indicated that the right ventricular failure in PIVSD may pose a risk for right-to-left PIVSD shunt under Impella support.

Delayed Treatment of Acute Myocardial Infarction With Ventricular Septal Rupture Due to Patient Fear During the COVID-19 Pandemic

During the coronavirus disease 2019 (COVID-19) pandmic, more patients are presenting with complications late after acute myocardial infarction. We report the case of a 71-year-old man who delayed seeking medical care for 2 weeks, despite progressive shortness of breath, cough, and tactile fever, for fear of contracting COVID-19 in the hospital. Clinical and echocardiographic evaluation revealed a ventricular septal rupture secondary to acute myocardial infarction. The patient underwent urgent cardiac catheterization, followed by successful saphenous vein grafting to the left anterior descending coronary artery and open surgical repair of the ventricular septal rupture with a bovine pericardial patch. This case highlights a potential long-lasting negative effect that the COVID-19 pandemic will have on the care-seeking behavior and health of patients with acute cardiovascular disease.

Assessment Framework for Recognizing Clinical Deterioration in Patients With ACS Undergoing PCI

TOPIC

Patients with acute coronary syndrome undergoing primary percutaneous coronary intervention are at risk of clinical deterioration that results in similar general signs and symptoms regardless of its cause. However, specific causes and forms of clinical deterioration are associated with key differences in assessment findings. Focused clinical assessments using a modified primary survey enable nurses to rapidly identify the cause and form of clinical deterioration, facilitating targeted treatment.

CLINICAL RELEVANCE

Clinical deterioration during percutaneous coronary intervention is associated with increased mortality and morbidity. Previous studies identified nursing inconsistencies when recognizing clinical deterioration, with inconsistent collection of cues and prioritization of cues related to cardiac performance over more sensitive indicators of clinical deterioration.

PURPOSE OF PAPER

To describe a framework to help nurses optimize physiological cue collection to improve recognition of clinical deterioration during periprocedural care of patients undergoing percutaneous coronary intervention for unstable acute coronary syndrome.

CONTENT COVERED

Literature analysis revealed 7 forms of clinical deterioration in patients undergoing percutaneous coronary intervention: coronary artery occlusion, stroke, ventricular rupture, valvular insufficiency, lethal cardiac arrhythmias, access-site and non-access-site bleeding, and anaphylaxis. Evidence for the pathophysiology, incidence, severity, and clinical features of each form of clinical deterioration is identified. A framework is proposed to help nurses conduct highly focused patient assessments, enabling prompt recognition of and response to the specific forms of clinical deterioration that occur in patients undergoing percutaneous coronary intervention.

Extended sandwich patch technique via right ventriculotomy for acute ventricular septal rupture

BACKGROUND

Surgical repair for post-infarction ventricular septal rupture (VSR) was still a challenging operation, especially when required in the acute phase or posterior VSR. ''Extended sandwich patch" technique is characterized by large double patches fixed by circumferential transmural large mattress sutures via right ventricle incision. In the present study, we report early and mid-term clinical and echocardiographic outcomes of this technique.

METHODS

Of 33 consecutive patients undergoing VSR repair using the extended sandwich patch technique between 2008 and 2018, 25 received surgery within 1 week from the onset of myocardial infarction (early group and 8 after 1 week (late group), including 12 patients with posterior VSR. All patients underwent surgery within 24 hours of VSR diagnosis.

RESULTS

Intraoperative transesophageal echo identified no residual shunt, but 2 patients received reoperative VSR repair at 9 days and 2 months after the first VSR repair. The 30-day mortality and one-year survival in the early and late groups were 20% and 12.5%, and 58% and 88%, respectively. After VSR repair, right and left heart chamber sizes were significantly decreased and these improvements were stable throughout the subsequent follow-up period (median 4.0 years). Tricuspid annular plane systolic excursion and right ventricular fractional area change remained constant throughout the observation period without changing after VSR repair.

CONCLUSIONS

The extended sandwich patch technique through a right ventriculotomy offered safe and simple, leak-free repair even in technically demanding acute phase or posterior VSR. No significant decline was found in the right heart function after surgery.

Mechanical Complications of Acute Myocardial Infarction: A Review

Importance

Mechanical complications of acute myocardial infarction include left ventricular free-wall rupture, ventricular septal rupture, papillary muscle rupture, pseudoaneurysm, and true aneurysm. With the introduction of early reperfusion therapies, these complications now occur in fewer than 0.1% of patients following an acute myocardial infarction. However, mortality rates have not decreased in parallel, and mechanical complications remain an important determinant of outcomes after myocardial infarction. Early diagnosis and management are crucial to improving outcomes and require an understanding of the clinical findings that should raise suspicion of mechanical complications and the evolving surgical and percutaneous treatment options.

Observations

Mechanical complications most commonly occur within the first week after myocardial infarction. Cardiogenic shock or acute pulmonary edema are frequent presentations. Echocardiography is usually the first test used to identify the type, location, and hemodynamic consequences of the mechanical complication. Hemodynamic stabilization often requires a combination of medical therapy and mechanical circulatory support. Surgery is the definitive treatment, but the optimal timing remains unclear. Percutaneous therapies are emerging as an alternative treatment option for patients at prohibitive surgical risk.

Conclusions and Relevance

Mechanical complications present with acute and dramatic hemodynamic deterioration requiring rapid stabilization. Heart team involvement is required to determine appropriate management strategies for patients with mechanical complications after acute myocardial infarction.

Targeted nanoscale therapeutics for myocardial infarction

Nanoscale therapeutics have promise for the administration of therapeutic small molecules and biologics to the heart following myocardial infarction. Directed delivery to the infarcted region of the heart using minimally invasive routes is critical to this promise. In this review, we will discuss the advances and design considerations for two nanoscale therapeutics engineered to target the infarcted heart, nanoparticles and adeno-associated viruses.