Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic

Mechanical Complication of Acute Myocardial Infarction Secondary to COVID-19 Disease

The aggressive inflammatory response to COVID-19 can result in airway damage, respiratory failure, cardiac injury, and multiorgan failure, which lead to death in susceptible patients. Cardiac injury and acute myocardial infarction (AMI) secondary to COVID-19 disease can lead to hospitalization, heart failure, and sudden cardiac death. When serious collateral damage from tissue necrosis or bleeding occurs, mechanical complications of myocardial infarction and cardiogenic shock can ensue. While prompt reperfusion therapies have decreased the incidence of these serious complications, patients who present late following the initial infarct are at increased for mechanical complications, cardiogenic shock, and death. The health outcomes for patients with mechanical complications are dismal if not recognized and treated promptly. Even if they survive serious pump failure, their CICU stay is often prolonged, and their index hospitalization and follow-up visits may consume significant resources and impact the health care system.

The Direct and Indirect Effects of COVID-19 on Acute Coronary Syndromes

The novel SARS-CoV-2 has directly and indirectly impacted patients with acute coronary syndrome (ACS). The onset of the COVID-19 pandemic correlated with an abrupt decline in hospitalizations with ACS and increased out-of-hospital deaths. Worse outcomes in ACS patients with concomitant COVID-19 have been reported, and acute myocardial injury secondary to SARS-CoV-2 infection is recognized. A rapid adaptation of existing ACS pathways has been required such that overburdened health care systems may manage both a novel contagion and existing illness. As SARS-CoV-2 is now endemic, future research is required to better define the complex interplay of COVID-19 infection and cardiovascular disease.

Ventricular Septal Rupture-The Resurgence of a Post-Myocardial Infarction Dreadful Complication during COVID-19 Pandemic

In the midst of the coronavirus disease-2019 (COVID-19) pandemic, an 84-year-old female patient was admitted due to non-exertional syncope preceded by retrosternal pain. She had experienced a prolonged episode of oppressive chest pain 6 days before her presentation, but due to the concern of contracting COVID-19, she did not present for medical care. Upon admission to the emergency department, the patient was in circulatory shock, with her physical examination being remarkable for the presence of a holosystolic murmur. Admission electrocardiogram revealed an inferior ST-segment elevation with Q waves with extension to the posterior wall, consistent with subacute infarct in the right coronary artery (RCA) territory, and the patient was transferred for primary percutaneous coronary intervention. Upon arrival to the catheterization laboratory, a summary transthoracic echocardiogram was performed, which revealed inferior wall and infero-septal akinesia with an 18 mm ventricular septal rupture. Coronary angiography documented occlusion of the proximal segment of a dominant RCA. Due to a high perioperative risk, the patient underwent successful retrograde percutaneous closure with a 24 mm MemoPart™ device, with mild to moderate residual shunt. Despite an immediate clinical improvement, the patient died 12 hours after the procedure due to refractory cardiogenic shock.

The Direct and Indirect Effects of COVID-19 on Acute Coronary Syndromes

The novel SARS-CoV-2 has directly and indirectly impacted patients with acute coronary syndrome (ACS). The onset of the COVID-19 pandemic correlated with an abrupt decline in hospitalizations with ACS and increased out-of-hospital deaths. Worse outcomes in ACS patients with concomitant COVID-19 have been reported, and acute myocardial injury secondary to SARS-CoV-2 infection is recognized. A rapid adaptation of existing ACS pathways has been required such that overburdened health care systems may manage both a novel contagion and existing illness. As SARS-CoV-2 is now endemic, future research is required to better define the complex interplay of COVID-19 infection and cardiovascular disease.

The Way Ahead: Life After COVID-19

Much has changed in the 2 years since the start of the coronavirus disease 19 (COVID-19) pandemic. The need for social distancing catalyzed the digitization of healthcare delivery and medical education—from telemedicine and virtual conferences to online residency/fellowship interviews. Vaccine development, particularly in the field of mRNA technology, led to widespread availability of safe and effective vaccines. With improved survival from acute infection, the healthcare system is dealing with the ever-growing cohort of patients with lingering symptoms. In addition, social media platforms have fueled a plethora of misinformation campaigns that have adversely affected prevention and control measures. In this review, we examine how COVID-19 has reshaped the healthcare system, and gauge its potential effects on life after the pandemic.

OUP accepted manuscript

The coronavirus disease 2019 (COVID-19) pandemic was a great burden for health care worldwide. We encountered 21 non-infected adult patients during 2020 who deferred to seek medical treatment since they thought that their difficulties to breathe were due to COVID-19. They were diagnosed late with cardiac disease with the indication for surgery. Deferred surgery for aortic stenosis was the cause of death in 1 patient. Long-standing not-treated endocarditis had caused severe aortic root pathology in 3 patients. Late-diagnosed ST-elevation myocardial infarction in 2 patients had caused papillary muscle and ventricular wall rupture. Eighteen of the patients finally underwent heart surgery at our tertiary care centre with early mortality of 22%. We conclude that late diagnosis of subjects requiring surgical treatment for heart disease was a risk for dismal outcomes during the COVID-19 pandemic.

Outpatient Wound Clinics During COVID-19 Maintained Quality but Served Fewer Patients

Objective

To evaluate the impact of COVID-19–related disruptions on care continuity and outcomes of chronic wounds.

Design

Retrospective cohort study.

Setting and Participants

Electronic medical records for 152,225 chronic wounds from a network of 488 wound care clinics in 45 US states and the District of Columbia.

Methods

Wound and patient characteristics, the number of chronic wounds newly seen at the clinics, and 12-week healing rates were compared between the first 2 quarters of 2019 and 2020. Multivariable regression models were constructed to evaluate whether the pandemic was associated with a statistically significant change in the probability of 12-week wound healing after risk adjustment.

Results

During the pandemic, wound and patient characteristics did not change compared to the previous year. Case volume dropped as much as 40% in April 2020 but returned to the previous year's level by June. No systematic changes in measures of care continuity were observed. Unadjusted 12-week healing rates remained stable at 0.502 in 2019 and 0.503 in 2020. Likewise, risk-adjusted 12-week healing rates were 0.504 and 0.505 in 2019 and 2020, respectively, but the difference was not statistically significant. States with stricter lockdowns saw a greater decline in case volume. However, the pandemic was not associated with a statistically significant change in the probability of 12-week wound healing in most states. The percentage of wounds with 1 or more telehealth visits increased from 0.14% in 2019 to 1.04% in 2020.

Conclusions and Implications

Despite COVID-19–related disruptions, our results suggest that wound care clinics maintained standards of care and outcomes for patients who sought care. This positive result should not detract from the problem that the number of new wounds seen at the clinics dropped sharply. Further research should evaluate outcomes in patients with unattended chronic wounds.

Excessive Hypoxia-Inducible Factor-1α Expression Induces Cardiac Rupture via p53-Dependent Apoptosis After Myocardial Infarction

Background

Apoptosis plays a pivotal role in cardiac rupture after myocardial infarction (MI), and p53 is a key molecule in apoptosis during cardiac rupture. Hif‐1α (hypoxia‐inducible factor‐1α), upregulated under hypoxia, is a known p53 inducer. However, the role of Hif‐1α in the regulatory mechanisms underlying p53 upregulation, apoptosis, and cardiac rupture after MI is unclear.

Methods and Results

We induced MI in mice by ligating the left anterior descending artery. Hif‐1α and p53 expressions were upregulated in the border zone at day 5 after MI, accompanied by apoptosis. In rat neonatal cardiomyocytes, treatment with cobalt chloride (500 μmol/L), which mimics severe hypoxia by inhibiting PHD (prolyl hydroxylase domain‐containing protein), increased Hif‐1α and p53, accompanied by myocyte death with caspase‐3 cleavage. Silencing Hif‐1α or p53 inhibited caspase‐3 cleavage, and completely prevented myocyte death under PHD inhibition. In cardiac‐specific Hif‐1α hetero‐knockout mice, expression of p53 and cleavage of caspase‐3 and poly (ADP‐ribose) polymerase were reduced, and apoptosis was suppressed on day 5. Furthermore, the cleavage of caspase‐8 and IL‐1β (interleukin‐1β) was also suppressed in hetero knockout mice, accompanied by reduced macrophage infiltration and matrix metalloproteinase/tissue inhibitor of metalloproteinase activation. Although there was no intergroup difference in infarct size, the cardiac rupture and survival rates were significantly improved in the hetero knockout mice until day 10 after MI.

Conclusions

Hif‐1α plays a pivotal role in apoptosis, inflammation, and cardiac rupture after MI, in which p53 is a critical mediator, and may be a prospective therapeutic target for preventing cardiac rupture.

COVID-19 and Cardiovascular Diseases: Challenges and Solutions

Rampantly spreading around the globe and taking thousands of lives each day, coronavirus disease 2019 (COVID-19) may present with varied cardiovascular manifestations. Those with evidence of myocardial injury have a worse prognosis too. Patients with pre-existing cardiovascular diseases or risk factors are at greater risk of adverse outcomes and mortality by this infection. Being highly contagious, measures to prevent cross-infection are of paramount importance. In this article, the authors summarize the various cardiovascular manifestations of COVID-19 and precautions needed while handling them and the long-term consequences of COVID-19 infection.

Recent insights into pathophysiology and management of mechanical complications of myocardial infarction

PURPOSE OF REVIEW

Mechanical complications of myocardial infarction are a group of postischemic events and include papillary muscle rupture resulting in ischemic mitral regurgitation, ventricular septal defect, left ventricle free wall rupture, pseudoaneurysm, and true aneurysm. Advances made in management strategies, such as the institution of 'Code STEMI' and percutaneous interventions, have lowered the incidence of these complications. However, their presentation is still associated with increased morbidity and mortality. Early diagnosis and appropriate management is crucial for facilitating better clinical outcomes.

RECENT FINDINGS

Although the exact timing of a curative intervention is not known, emerging percutaneous and transcatheter approaches and improving mechanical circulatory support (MCS) devices have greatly enhanced our ability to manage and treat some of the complications postinfarct.

SUMMARY

Although the incidence of mechanical complications of myocardial infarction has decreased over the past few decades, these complications are still associated with high rates of morbidity and mortality. The combination of early and accurate diagnosis and subsequent appropriate management are imperative for optimizing clinical outcomes. Although more randomized clinical trials are needed, mechanical circulatory support devices and emerging therapeutic strategies can be offered to carefully selected patients.

COVID-19 and Acute Myocardial Injury and Infarction: Related Mechanisms and Emerging Challenges

In the era of the coronavirus disease 2019 (COVID-19) pandemic, acute cardiac injury (ACI), as reflected by elevated cardiac troponin above the 99th percentile, has been observed in 8%-62% of patients with COVID-19 infection with highest incidence and mortality recorded in patients with severe infection. Apart from the clinically and electrocardiographically discernible causes of ACI, such as acute myocardial infarction (MI), other cardiac causes need to be considered such as myocarditis, Takotsubo syndrome, and direct injury from COVID-19, together with noncardiac conditions, such as pulmonary embolism, critical illness, and sepsis. Acute coronary syndromes (ACS) with normal or near-normal coronary arteries (ACS-NNOCA) appear to have a higher prevalence in both COVID-19 positive and negative patients in the pandemic compared to the pre-pandemic era. Echocardiography, coronary angiography, chest computed tomography and/or cardiac magnetic resonance imaging may render a correct diagnosis, obviating the need for endomyocardial biopsy. Importantly, a significant delay has been recorded in patients with ACS seeking advice for their symptoms, while their routine care has been sharply disrupted with fewer urgent coronary angiographies and/or primary percutaneous coronary interventions performed in the case of ST-elevation MI (STEMI) with an inappropriate shift toward thrombolysis, all contributing to a higher complication rate in these patients. Thus, new challenges have emerged in rendering a diagnosis and delivering treatment in patients with ACI/ACS in the pandemic era. These issues, the various mechanisms involved in the development of ACI/ACS, and relevant current guidelines are herein reviewed.

Initial Findings From the North American COVID-19 Myocardial Infarction Registry

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI).

OBJECTIVES

The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI.

METHODS

A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization.

RESULTS

As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients).

CONCLUSIONS

COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.

Simultaneous Left Ventricular Aneurysm and Ventricular Septal Rupture Complicating Delayed STEMI Presentation: A Case-Based Review of Post-MI Mechanical Complications Amid the COVID-19 Pandemic

Amid the coronavirus disease 2019 (COVID-19) pandemic, there is an unprecedented increase in public avoidance of hospitals predominantly driven by fear of contracting the virus. Recent publications highlight a re-emergence of rare post-myocardial infarction complications. While mechanical complications are infrequent in the era of primary percutaneous coronary intervention, they are associated with high mortality rates. The concurrent occurrence of mechanical complications such as left ventricular aneurysm and ventricular septal rupture is an extremely rare entity. We hereby delineate a unique case of a 53-year-old Caucasian male who underwent successful concomitant closure of a ventricular septal rupture, left ventricular aneurysmectomy, and 3-vessel coronary artery bypass grafting. Due to a delayed initial presentation owing to the patient's fear of contracting COVID-19, the surgery was carried out 3 months after the myocardial infarction. His postoperative evaluation confirmed normal contractility of the left ventricle and complete closure of the ventricular septal rupture. Six months postoperatively, the patient continues to do well. We also present a literature review of the mechanical complications following delayed presentation of myocardial infarction amid the COVID-19 pandemic. This article illustrates that clinicians should remain cognizant of these extremely rare but potentially lethal collateral effects during the ongoing global public-health challenge. Furthermore, it highlights a significant concern regarding the delay in first medical contact due to the reluctance of patients to visit the hospital during the COVID-19 pandemic.

Community and healthcare system-related factors feeding the phenomenon of evading medical attention for time-dependent emergencies during COVID-19 crisis

The current COVID-19 crisis has significantly impacted healthcare systems worldwide. There has been a palpable increase in public avoidance of hospitals, which has interfered in timely care of critical cardiovascular conditions. Complications from late presentation of myocardial infarction, which had become a rarity, resurfaced during the pandemic. We present two such encounters that occurred due to delay in seeking medical care following myocardial infarction due to the fear of contracting COVID-19 in the hospital. Moreover, a comprehensive review of literature is performed to illustrate the potential factors delaying and decreasing timely presentations and interventions for time-dependent medical emergencies like ST-segment elevation myocardial infarction (STEMI). We emphasise that clinicians should remain vigilant of encountering rare and catastrophic complications of STEMI during this current era of COVID-19 pandemic.