Temporal Trends and Outcomes of Mechanical Complications in Patients With Acute Myocardial Infarction

Mechanical circulatory support: when, how, and for whom

Cardiogenic shock represents a critical condition in which the heart is unable to maintain adequate circulation leading to insufficient tissue perfusion and end-organ failure. Temporary mechanical circulatory support offers the potential to stabilize patients, provide a bridge-to-recovery, provide a bridge-to-decision, or facilitate definitive heart replacement therapies. Although randomized controlled trials have been performed in infarct-related cardiogenic shock and refractory cardiac arrest, the optimal timing, appropriate patient selection, and optimal implementation of these devices remain complex and predominantly based on observational data and expert consensus, especially in non-ischaemic shock. This review explores the details of 'when, how, and for whom' temporary mechanical circulatory support devices should be used, examining specific clinical scenarios, the mechanisms by which they operate, and the patient populations that may benefit. The review also highlights the many gaps in evidence and need for better understanding of the interaction between human biology and these devices.

Long-Term Prognosis of Postinfarction Ventricular Septal Rupture: A Single-Center Experience

OBJECTIVE

This seven-year study investigates risk factors for long-term mortality in AMI patients with ventricular septal rupture (VSR) to enhance clinical management and outcomes.

METHODS

We conducted a retrospective cohort study of 180 AMI patients with VSR from January 2016 to October 2023. We collected data on demographics, clinical features, treatments, and outcomes. Patients were divided into survival and death groups and further classified by treatment (surgical repair vs. medical management). Cox proportional hazards regression identified predictors of long-term mortality.

RESULTS

Median follow-up was 1028 days, with an overall mortality rate of 65.6%. The death group had a higher rate of medical management (83.1% vs. 35.5% in survivors). Long-term mortality rates were 33.3% for surgical repair and 81.7% for medical management. Independent predictors of poor outcomes included Killip Class 3-4, female gender, and advanced age. Surgical repair was a protective factor against mortality (HR 0.232). Killip Class 3-4 (HR 5.154) was a significant independent risk factor for long-term mortality among surgical patients. Killip Class 3-4 (HR, 3.268) and female gender (HR 2.548) were significant independent risk factors for long-term mortality among medical management patients.

CONCLUSION

Surgical repair significantly reduces long-term mortality compared to medical management in AMI patients with VSR. Killip Class 3-4 affects prognosis, emphasizing the need for tailored management strategies.

Untangling Mechanical Complications of Acute Myocardial Infarction

Mechanical complications after acute myocardial infarction, including left ventricular free wall rupture, ventricular septal rupture, papillary muscle rupture, and pseudoaneurysm, although infrequent, are associated with significant morbidity and mortality. Despite the reduction in incidence because of early reperfusion therapies, their associated mortality rates remain disproportionately high. This disparity highlights the critical need for early detection and prompt intervention, which are key to improving patient outcomes in the postinfarction period. Timely restoration of coronary blood flow is essential for preventing complications, with reperfusion strategies, particularly percutaneous coronary intervention, serving as a cornerstone in minimizing ischemic injury. This review aims to provide an in-depth evaluation of the clinical, diagnostic, and therapeutic approaches to these mechanical complications with illustrative case studies to facilitate practical understanding of these conditions.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Transcatheter Mitral Valve Repair for an Extremely High Surgical Risk Acute Mitral Regurgitation Patient

Transcatheter edge to edge repair (TEER) has been proven to be safe and effective for mitral regurgitation (MR) caused by acute myocardial infarction (AMI). However, for some specific conditions, such as papillary muscle rupture complicating AMI, the feasibility of TEER is not yet fully determined. A 74-year-old woman with coronary disease developed acute MR and heart failure after AMI. Transesophageal echocardiography confirmed severe MR due to papillary muscle rupture. The patient underwent emergency TEER, which successfully reduced MR and improved symptoms. This case highlights the life-saving potential of the Dragonfly TEER system in treating acute MR after MI, particularly in patients with extremely high surgical risk.

Surgical versus percutaneous closure of post-infarction ventricular septal rupture; review of literature and single-center experience

BACKGROUND

Post-infarction ventricular septal rupture (PIVSR) is a rare mechanical complication, characterized by a dismal prognosis. Despite the widespread timely reperfusion and recent advances in management, short-term mortality of PIVSR remains high. The complexity of the hemodynamic profile, confusing evidence for the optimal timing for intervention, and lack of head-to-head trials, all make the management of such a condition very challenging.

METHODS

The database of a tertiary cardiac center was retrospectively analyzed for PIVSR cases through the period from April 2015 to April 2023. Clinical, echocardiographic, and interventional data were explored. The primary outcome was 30-day mortality that was contrasted for surgical versus percutaneous repair.

RESULTS

A total of 32 patients with PIVSR were identified. The median age was 65 years, 50% were males, 56% had diabetes, and 50% had cardiogenic shock (CS) on presentation, with a median time of 3 days from acute myocardial infarction (AMI) to PIVSR diagnosis. The median left ventricular ejection fraction (LVEF) was 38%. Culprit vessel patency was acutely restored in 26 patients (81%), while intra-aortic balloon pump (IABP) was inserted in 25 (78%). Upfront insertion of IABP (in the absence of CS) showed a trend towards improved survival (43% vs. 9%). PIVSR was surgically repaired in 15 patients (47%), while 9 (28%) underwent percutaneous device closure, with no significant difference in outcomes and with a median time to intervention of 21 days for both groups. The overall 30-day mortality rate was 44%. Acute kidney injury (AKI) was a significant predictor for 30-day mortality (odds ratio 7.5, 95%CI: 1.3 - 43.7, p = 0.028).

CONCLUSION

PIVSR still carries a grave prognosis. Early surgical or percutaneous intervention seems associated with higher mortality, while upfront insertion of IABP for a safe deferral of repair beyond the acute phase may lead to better outcomes. Larger randomized studies are required to dictate the best management.

Surgical repair for postinfarction left ventricular free-wall rupture: 25-year single-centre experience†

OBJECTIVES

Postinfarction left ventricular free-wall rupture (LVFWR) is a rare, unpredictable and often fatal complication of acute myocardial infarction. We reviewed our surgical experience with postinfarction LVFWR over 25 years to identify risk factors for in-hospital mortality.

METHODS

Seventy-two consecutive patients with LVFWR who underwent surgical repair between 1994 and 2023 were retrospectively analysed. The primary end point was in-hospital mortality. The mean follow-up period was 3.9 ± 5.4 years (maximum 25 years, 283 patient-years).

RESULTS

Thirty-five patients (49%) were directly transported to our centre, whereas 37 (51%) were initially taken to a local hospital. Prior to surgery, 30 (42%) developed out-of-hospital (n = 8, 11%) or in-hospital (n = 22, 31%) cardiac arrest. Upon entry to the operating room, 45 (63%) presented hypotensive shock, while 27 (38%) suffered cardiac arrest. LVFWR was oozing type in 42 patients (58%) and blow-out type in 30 patients (42%), for which sutureless repair (n = 27, 38%) or sutured repair (n = 45, 62%) was performed. The in-hospital mortality rate was 35%, in association with haemodynamic condition before surgery: 19% in patients without cardiac arrest, and 55% with in-hospital and 63% with out-of-hospital cardiac arrest. Patient age [adjusted odds ratio (OR) 2.2 per 10-year period, 95% confidence interval (CI) 1.0-4.9, P = 0.044], out-of-hospital cardiac arrest (adjusted OR 8.6, 95% CI 1.4-66, P = 0.020), in-hospital cardiac arrest (adjusted OR 6.6, 95% CI 1.6-33, P = 0.010) and initial ambulance transport to a local hospital (adjusted OR 4.2, 95% CI 1.2-17, P = 0.020) were identified as independent risk factors of in-hospital mortality. The overall 5-year survival rate was 50%, while that for in-hospital survivors was 77%. When the present study period is split into 2 eras (1994-2010 and 2011-2023), the in-hospital mortality rate was comparable between them (41% vs 31%, P = 0.408). Notably, the in-hospital mortality of patients with a blow-out type left ventricular rupture was significantly lower in that latter study period (86% vs 39%, P = 0.025).

CONCLUSIONS

In surgically treated patients with LVFWR, the early mortality rate was high, while the long-term prognosis for in-hospital survivors was acceptable. These findings highlight the need for early diagnosis and prompt management of haemodynamic instability at a tertiary centre to improve outcomes.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

[Management of acute coronary syndrome]

Coronary artery disease (CAD) is the leading cause of death worldwide. Acute coronary syndrome (ACS) encompasses a spectrum of diagnoses ranging from unstable angina pectoris to myocardial infarction with and without ST-segment elevation and frequently presents as the first clinical manifestation. It is crucial in this scenario to perform a timely and comprehensive assessment of patients by evaluating the clinical presentation, electrocardiogram and laboratory diagnostics using highly sensitivity cardiac troponin in order to initiate a timely and risk-adapted continuing treatment with immediate or early invasive coronary angiography. In addition to revascularization, the subsequent antithrombotic and lipid-lowering treatment plays a major role in the further secondary prevention of CAD. The choice and duration of medication over time should be tailored to the individual risk profile of the patient. Furthermore, appropriate patient education regarding risk factor management is of paramount importance.

Transcatheter edge-to-edge repair in severe mitral regurgitation following acute myocardial infarction - aetiology-based analysis

AIMS

To evaluate the association between transcatheter edge-to-edge repair (TEER) and outcomes in patients with significant mitral regurgitation (MR) following acute myocardial infarction (MI), focusing on the aetiology of acute post-MI MR in high-risk surgical patients.

METHODS AND RESULTS

The International Registry of MitraClip in Acute Mitral Regurgitation following Acute Myocardial Infarction (IREMMI) includes 187 patients with severe MR post-MI managed with TEER. Of these, 176 were included in the analysis, 23 (13%) patients had acute papillary muscle rupture (PMR) and 153 (87%) acute secondary MR. The mean age was 70 ± 10 years and 41% were female. PMR patients had fewer cardiovascular risk factors: hypertension (52% vs. 73%, p = 0.04), diabetes (26% vs. 48%, p < 0.01) but a higher left ventricular ejection fraction (45±  15% vs.35±  10%, p < 0.01) compared secondary MR patients. PMR patients were more likely to present in cardiogenic shock (91% vs. 51%, p = 0.001), require mechanical circulatory support (74% vs. 34%, p = 0.01), and had a higher EuroSCORE II (23±  13% vs. 13±  11%, p = 0.011). The median time from MI to TEER was shorter in PMR (6 days) versus secondary MR (20 days) (p < 0.01). Procedural success was similar (87% vs. 92%, p = 0.49) with comparable MR grade reduction. However, PMR patients had significantly higher in-hospital mortality rates (adjusted odds ratio [OR] 3.05, 95% confidence interval [CI] 1.15-8.12, p = 0.02), 30-day mortality rates (unadjusted OR 3.99, 95% CI 1.42-11.26, p = 0.01) and a higher rate of conversion to surgical mitral valve replacement (22% vs. 3%, p < 0.01) (unadjusted OR 8.17, 95% CI 2.15-30.96, p < 0.001). Aetiology of MR, cardiogenic shock, and procedure timing significantly impacted in-hospital mortality. After adjusting for EuroSCORE II and cardiogenic shock, MR aetiology remained the strongest predictor (adjusted OR 6.71; 95% CI 2.06-21.86, p < 0.01).

CONCLUSION

Transcatheter edge-to-edge repair may be considered a salvage or bridge procedure in decompensated post-MI MR patients of both aetiologies; however, patients with PMR have a higher risk of mortality and conversion to surgery.

Post-myocardial infarction ventricular septal defects: incidence and treatment trends during and after the COVID-19 pandemic

Ventricular septal defect (VSD) is a serious complication of myocardial infarction (MI), with its global incidence significantly reduced in recent years due to advances in coronary reperfusion techniques. However, during the COVID-19 pandemic, there was an unexpected rise in the incidence of post-MI VSD, likely driven by delays in seeking treatment. This study retrospectively analyzed 10 cases of post-MI VSD treated at our hospitals from March 2018 to August 2023, comparing incidence rates across pre-pandemic, pandemic, and post-pandemic periods. The findings revealed a notable increase in VSD cases during the pandemic, with six cases occurring in two years, compared to only two cases in each of the pre-pandemic and post-pandemic periods. Despite these fluctuations, surgical intervention remained a crucial and effective treatment, with 60% of patients surviving the 30-day follow-up. The study underscores the impact of delayed treatment on VSD incidence during the pandemic and highlights the critical need for timely medical intervention to manage severe MI complications effectively.

Incidence and risk factors for cardiac rupture after ST-segment elevation myocardial infarction in contemporary era: findings from the improving care for cardiovascular disease in China-Acute Coronary Syndrome project

Cardiac rupture (CR) is fatal mechanical complication of ST-segment elevation myocardial infarction (STEMI). We systematically analyzed the clinical features of STEMI patients with CR, as well as predictors and treatments associated with risk of CR in contemporary era. In this nationwide database, 49,284 patients admitted within 48 h after STEMI were enrolled, and were stratified according to CR status. We analyzed patients' clinical characteristics, case fatality rate, and independent correlates of CR. A total of 188 (0.38%) patients had CR, of which 42.6% died during hospitalization. Older age, female gender, higher heart rate, history of diabetes, and worse cardiac function were risk factors of CR in patients with STEMI, while a previous history of myocardial infarction was associated with a reduced risk of CR. CR patients were less likely to undergo primary percutaneous coronary intervention (PCI). After adjustment, primary PCI was associated with 56% decreased risk of CR (OR 0.44, 95% CI 0.29-0.67). This result was consistent in the propensity-score matching analysis and inverse probability of treatment weighting analysis. CR was associated with high in-hospital mortality among STEMI patients. Multiple factors were associated with CR occurrence, primary PCI was associated with lower risk of CR, indicating that early intervention targeting the risk factors and implementation of primary PCI may improve its prognosis. Clinical trial registration ClinicalTrials.gov; Number: NCT02306616; URL: www.clinicaltrials.gov.

A Case of the Utility of Viscoelastic Testing for the Management of the Impella Device in Heparin Anticoagulation

The main anticoagulant therapy with Impella is unfractionated heparin (UFH), with manufacturers recommending a target therapeutic range of 160-180 seconds for activated clotting time (ACT). However, the ACT assay does not have uniform criteria, and many available devices contain a variety of activators, making it difficult to compare them individually. We used Impella CP in the perioperative management of a post-myocardial infarction ventricular septal rupture in a 69-year-old man. A significant amount of UHF was used in this case, but as the ACT did not reach the recommended range, blood viscoelasticity testing (VET) was adopted as an alternative point-of-care test (POCT). The initial measurement results showed a clot time (CT) of 308 seconds, a heparinase clot time (CTH) of 161 seconds, and a clot time ratio (CTR) of 1.9, indicating that UFH was sufficiently active. Continuous administration of UFH was then performed with reference to VET, which was terminated three hours before surgery. As an alternative POCT to ACT, the VET may be suitable for assessing low doses of UFH effectiveness with heparinase assay, which provides specific measures of the heparin effect, such as CTR, and minimizes the variability in results as compared to ACT.

The role of Impella in the pre-procedural management of post-infarct ventricular septal defect: a systematic review

OBJECTIVES

Post-infarct ventricular septal defect is a rare but devastating complication. Delayed treatment offers better outcomes than emergency surgery, but when acute cardiogenic shock or unstable haemodynamics occur, temporary mechanical circulatory support may be needed to stabilize patients until treatment. The aim of our systematic review was to assess the outcomes of using Impella in this setting.

METHODS

A systematic search was performed in the Medline and EMBASE databases, and all the papers about the use of Impella in this setting were assessed. The study followed the PRISMA criteria.

RESULTS

A total of 20 papers encompassing 68 patients with an Impella implanted after the diagnosis of post-infarct ventricular septal defect and before its treatment were included. More than 95% were in cardiogenic shock when Impella was implanted, and half had another mechanical circulatory support device. Most of the patients (62%) had a posterior defect, and 72% underwent surgical or percutaneous repair. Total in-hospital mortality was 47%, and a total of 29 Impella-related complications were observed. Patients with surgical Impella had a numerically lower in-hospital mortality (35% vs. 58%) and a lower rate of complications compared to percutaneous device.

CONCLUSIONS

Impella represents an effective device for diminishing low output syndrome, improving peripheral perfusion, and unloading both the ventricles. It can be used as an upgrade from another mechanical circulatory support or as an addition to extracorporeal membrane oxygenation to provide adequate left ventricular or biventricular support. Despite this, Impella-related complications can occur after its implantation and must be considered.

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

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 the early and long-term results of patients undergoing surgical treatment for post-AMI MCs.

METHODS AND RESULTS

Patients who underwent surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centres worldwide were retrieved from the database of the 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. 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 post-operative LCOS (P < 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significantly higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022).

CONCLUSION

Contemporary data from a multicentre 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 post-operative period is encouraging.

Trends in the incidence, mortality and clinical outcomes in patients with ventricular septal rupture following an ST-elevation myocardial infarction

BACKGROUND

Despite improvements in outcomes of ST elevation myocardial infarction (STEMI), ventricular septal rupture (VSR) remains a known complication, carrying high mortality. The contemporary incidence, mortality, and management of post-STEMI VSR remains unclear.

METHODS

The National Inpatient Sample database (2009-2020) was used to study trends in admissions and outcomes of post-STEMI VSR over time. Survey estimation commands were used to determine weighted national estimates.

RESULTS

There were 2 315 186 ± 22 888 visits for STEMI with 0.194 ± 0.01% experiencing VSR during 2009-2020 in the USA. Patients with VSR were more often older, white, female, and presented with an anterior STEMI; there was no difference in the rates of fibrinolysis. In-hospital mortality was 73.6 ± 1.8%, but only 29.2 ± 1.9 and 10 ± 1.2% received surgical repair and transcatheter repair (TCR), respectively. TCR was associated with higher and surgical repair with lower mortality. Days to surgery were longer for those who survived (5.9 ± 2.75) compared with those who died (2.44 ± 1). In a multivariable analysis, surgical repair at greater than or equal to day 4 was associated with lower in-hospital mortality (odds ratio = 0.39, 95% confidence interval: 0.17-0.88).

CONCLUSION

Mortality in post-STEMI VSR remains high with no improvement over time. Most patients are managed conservatively, and the frequency of surgical repair has decreased, while TCR has increased over the study period. Despite design limitations and survival bias, surgical repair at greater than or equal to 4 days was associated with a lower mortality.

Cardiogenic shock

Cardiogenic shock is a complex syndrome defined by systemic hypoperfusion and inadequate cardiac output arising from a wide array of underlying causes. Although the understanding of cardiogenic shock epidemiology, specific subphenotypes, haemodynamics, and cardiogenic shock severity staging has evolved, few therapeutic interventions have shown survival benefit. Results from seminal randomised controlled trials support early revascularisation of the culprit vessel in infarct-related cardiogenic shock and provide evidence of improved survival with the use of temporary circulatory support in selected patients. However, numerous questions remain unanswered, including optimal pharmacotherapy regimens, the role of mechanical circulatory support devices, management of secondary organ dysfunction, and best supportive care. This Review summarises current definitions, pathophysiological principles, and management approaches in cardiogenic shock, and highlights key knowledge gaps to advance individualised shock therapy and the evidence-based ethical use of modern technology and resources in cardiogenic shock.

Impact of treatment management on the hospital stay in patients with acute coronary syndrome

BACKGROUND

The length of hospital stay in patients with acute coronary syndrome (ACS) is crucial for determining clinical outcomes, managing healthcare resources, controlling costs, and ensuring patient well-being. This study aimed to explore the impact of treatment approaches on the length of stay (LOS) for ACS patients.

METHODS

A total of 7109 ACS cases were retrospectively recruited from a hospital between 2018 and 2023. Demographical baseline data, laboratory examinations, and diagnostic and treatment information of the included subjects were extracted from electronic medical records to investigate the factors contributing to extended hospitalization and further explore the impact of treatment management on the LOS.

RESULTS

Advanced age, female sex, and elevated levels of B-type natriuretic peptide, C-reactive protein and higher low-density lipoprotein cholesterol were identified as risk factors for extended hospitalization. At the 0.2-0.9 quantile of LOS, compared with the non-invasive group, the percutaneous transluminal coronary angioplasty group and the stent implantation group exhibited decreases in LOS of 0.37-2.37 days and 0.12-2.28 days, respectively. Stratified analysis based on diagnosis showed that percutaneous coronary intervention decreased hospitalization time in the high quantile of LOS but conversely increased it in the low quantile.

CONCLUSION

Percutaneous coronary intervention is important for reducing hospitalization duration, particularly for patients susceptible to prolonged stays. Early and assertive management intervention, incorporating elements such as lipid-lowering therapy, and anti-inflammatory agents, is essential for improving outcomes within high-risk groups.

A Case of an Interventricular Septum Pseudoaneurysm With Perforation Mimicking a Ventricular Septal Defect

Ventricular pseudoaneurysm (PSA) is a ventricular outpouching contained by adherent pericardium or myocardial scar tissue and represents a rare but potentially fatal complication of acute myocardial infarction (AMI). The vast majority of cases involve the left ventricular apex, in the area of infarct. It is extremely rare to see PSA formation within the interventricular septum (IVS). We present a case of ventricular PSA of the IVS, with contained perforation into the right ventricle, mimicking a ventricular septal defect (VSD) in a patient presenting with ST-elevation myocardial infarction (STEMI). This case underscores the importance of maintaining a high index of clinical suspicion and reviews the pathophysiological mechanisms and treatment options for these life-threatening mechanical complications.

Survival and Recovery From Postmyocardial Infarction Apical Wall Rupture With a Complex Course

Ventricular wall rupture is associated with poor outcomes subsequent to an acute myocardial infarction. We describe a case of postmyocardial infarction apical wall rupture following percutaneous coronary intervention. Our case emphasizes the importance of swift evaluation, diagnosis, and management to enhance survival in individuals confronting this critical condition.

The short-term outcomes and risk factors of post-myocardial infarction ventricular septal rupture: a multi-center retrospective Study

OBJECTIVES

Post-myocardial infarction ventricular septal rupture (PIVSR) is one of the most severe types of mechanical complications after acute myocardial infarction (AMI) with high mortality and poor prognosis. The risk factors for short-term mortality of patients with PIVSR may be not widely recognized. We aimed to assess the prevalence and short-term mortality risk predictors of PIVSR.

METHODS

A total of 62 patients with a diagnosis of PIVSR were admitted to three top general public hospitals in Chongqing, China. Clinical characteristics and short-term outcomes of patients with PIVSR were compared. Predictors of PIVSR were assessed using logistic regression analysis.

RESULTS

Mean age was 70.7 ± 10.7 years (38.7% female). The overall in-hospital mortality of PIVSR remained high (71%). Most (47/62) of the patients were in Killip class III or IV at the time of rupture diagnosis. Logistic regression analysis revealed that white blood cell count (WBC, OR 1.619, 95% CI 1.172-2.237, P = 0.005), cardiogenic shock (OR 47.706, 95%CI 2.859-795.945, P = 0.007) and left ventricular ejection fraction (LVEF, OR 0.803, 95%CI 0.689-0.936, P = 0.009) were independent risk factors of in-hospital early mortality. The nomogram developed for predicting the risk of short-term mortality showed a robust discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.956 (95%CI 0.912-1.000).

CONCLUSION

The short-term mortality of PIVSR remained high. WBC, cardiogenic shock, and LVEF were the independent predictive factors of short-term mortality. Our nomogram might be used to predict early mortality of patients with PIVSR.

Hydrogel formulations for orthotopic treatment of myocardial infarction

INTRODUCTION

Myocardial infarction (MI) causes extensive structural and functional damage to the cardiac tissue due to the significant loss of cardiomyocytes. Early reperfusion is the standard treatment strategy for acute MI, but it is associated with adverse effects. Additionally, current therapies to alleviate pathological changes post-MI are not effective. Subsequent pathological remodeling of the damaged myocardium often results in heart failure. Oral drugs aimed at reducing myocardial damage and remodeling require repeated administration of high doses to maintain therapeutic levels. This compromises efficacy and patient adherence and may cause adverse effects, such as hypotension and liver and/or kidney dysfunction. Hydrogels have emerged as an effective delivery platform for orthotopic treatment of MI due to their high water content and excellent tissue compatibility.

AREA COVERED

Hydrogels create an optimal microenvironment for delivering drugs, proteins, and cells, preserving their efficacy and increasing their bioavailability. Current research focuses on discovering functional hydrogels for mitigating myocardial damage and regulating repair processes in MI treatment.

EXPERT OPINION

Hydrogels offer a promising approach in enhancing cardiac repair and improving patient outcomes post-MI. Advancements in hydrogel technology are poised to transform MI therapy, paving the way for personalized treatment strategies and enhanced recovery.

Management of Myocardial Infarction and the Role of Cardiothoracic Surgery

Myocardial infarction (MI) is a leading cause of mortality globally and is predominantly attributed to coronary artery disease (CAD). MI is categorized as ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI), each with distinct etiologies and treatment pathways. The goal in treatment for both is restoring blood flow back to the myocardium. STEMI, characterized by complete occlusion of a coronary artery, is managed urgently with reperfusion therapy, typically percutaneous coronary intervention (PCI). In contrast, NSTEMI involves a partial occlusion of a coronary artery and is treated with medical management, PCI, or coronary artery bypass grafting (CABG) depending on risk scores and clinical judgment. The Heart Team approach can assist in deciding which reperfusion technique would provide the greatest benefit to the patient and is especially useful in complicated cases. Despite advances in treatment, complications such as cardiogenic shock (CS) and ischemic heart failure (HF) remain significant. While percutaneous coronary intervention (PCI) is considered the primary treatment for MI, it is important to recognize the significance of cardiac surgery in treatment, especially when there is complex disease or MI-related complications. This comprehensive review analyzes the role of cardiac surgery in MI management, recognizing when it is useful, or not.

Preoperative Impella therapy in patients with ventricular septal rupture and cardiogenic shock: haemodynamic and organ function outcomes

OBJECTIVES

We examined the effects of preoperative Impella treatment on haemodynamic stability, organ recovery and postoperative outcomes in patients with postinfarction ventricular septal rupture (PIVSR) and cardiogenic shock (CS).

METHODS

Between April 2018 and February 2024, the data of 10 of 15 patients with PIVSR and CS who underwent Impella therapy were analysed. Emergency surgery was contingent on haemodynamic stability with the Impella/ECpella, except in the presence of organ failure. We utilized a generalized linear mixed model to evaluate organ ischaemia through changes in blood parameters upon admission and at subsequent intervals post-Impella insertion.

RESULTS

Preoperative Impella or combined Impella and ECpella (5 patients each) support was provided, with diagnoses and operations occurring at an average of 4 days (interquartile range: 2-5) and 8 days (interquartile range: 2-14) after myocardial infarction, respectively. Treatment significantly reduced lactate, alanine aminotransferase, creatine kinase-MB and troponin I levels (P ≤ 0.05 for all). Conversely, no significant change was noted in the aspartate aminotransferase level or the estimated glomerular filtration rate. Haemoglobin and platelet counts decreased despite transfusions (P < 0.001). No surgical deaths occurred; however, 70% of the patients required prolonged mechanical ventilation, and 80% were transferred to other facilities for rehabilitation.

CONCLUSIONS

Impella or ECpella treatment can improve haemodynamic and organ failure outcomes in patients with PIVSR and CS. However, the risks of prolonged support, including haemorrhagic events and the need for extended rehabilitation, point to a need for comparative studies to optimize support duration.

Determinants of serious in-hospital complications in patients with Killip class 1/2 ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention

Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.

Development of a nomogram to predict 30-day mortality in patients with post-infarction ventricular septal rupture

Ventricular septal rupture (VSR) is a mechanical complication of acute myocardial infarction (AMI), and its mortality has not decreased significantly in recent decades. However, no clinical model has been developed to predict short-term mortality in patients with post-infarction VSR (PIVSR). This study aimed to develop a nomogram to predict the 30-day mortality by using the clinical characteristics of hospitalized patients with PIVSR. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis was used to construct a nomogram by R. The model was evaluated by the area under the curve (AUC), calibration curve and decision curve analysis (DCA). The bootstrap method was used to validate the model internally. As a result, a nomogram was constructed by using six variables, including CRRT, mechanical ventilation, PPCI, WBC, PASP and methods of treatment. The AUC of the prediction model was 0.96 (0.93, 0.98). The prediction model was well calibrated. The DCA showed that if the threshold probability was between 15% and 95%, the nomogram model would provide a net benefit. The well-constructed and evaluated nomogram can be beneficial to clinicians to predict the risk of death within 30 days in patients with PIVSR.

The predictive value of neutrophil-lymphocyte ratio combined with the Global Registry of Acute Coronary Events score for inhospital adverse cardiovascular events in patients with acute ST-elevation myocardial infarction

Background

The research explores the predictive efficacy of the neutrophil-to-lymphocyte ratio (NLR) in conjunction with the Global Registry of Acute Coronary Events (GRACEs) score for inhospital major adverse cardiovascular events (MACEs) among acute ST-segment elevation myocardial infarction (STEMI) subjects with primary percutaneous coronary intervention (PCI) history.

Materials and Methods

Patients were categorized into MACE (n = 58) and non-MACE cohorts (n = 184) based on MACE occurrence events during hospitalization. The predictive value of the NLR, GRACE score, and their combination for inhospital MACE events in STEMI subjects was assessed by the receiver operating characteristic curve (ROC).

Results

NLR (8.99 [5.06, 12.01] vs. 5.15 [3.13, 7.66]) and GRACE scores (159.62 ± 43.39 vs. 116.96 ± 28.15) within MACE group notably surpassed the non-MACE group (P < 0.05). ROC curve analysis demonstrated that the area under the curve (AUC) for NLR in forecasting inhospital MACE events was 0. 72 (95% confidence interval [CI]: 0.645-0.795), with 0.655 sensitivity and 0.723 specificity, and optimal cutoff value as 7.01. The AUC for the GRACE score was 0.791 (95% CI: 0.717-0.865), with 0.862 sensitivity and 0.598 specificity, and the optimal cutoff value was 121.5. The combined AUC of NLR and GRACE score was 0.814 (95% CI: 0.745-0.884), with 0.707 sensitivity and 0.837 specificity.

Conclusion

Both NLR and GRACE score independently predict inhospital MACE events in STEMI patients post-PCI. Integration of the NLR and GRACE score enhances accuracy in forecasting inhospital MACE event occurrences.

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.

From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion

Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.

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.

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.

Management of Severe Mitral Regurgitation in Patients With Acute Myocardial Infarction: JACC Focus Seminar 2/5

Severe acute mitral regurgitation after myocardial infarction includes partial and complete papillary muscle rupture or functional mitral regurgitation. Although its incidence is <1%, mitral regurgitation after acute myocardial infarction frequently causes hemodynamic instability, pulmonary edema, and cardiogenic shock. Medical management has the worst prognosis, and mortality has not changed in decades. Surgery represents the gold standard, but it is associated with high rates of morbidity and mortality. Recently, transcatheter interventions have opened a new door for management that may improve survival. Mechanical circulatory support restores vital organ perfusion and offers the opportunity for a steadier surgical repair. This review focuses on the diagnosis and the interventional management, both surgical and transcatheter, with a glance on future perspectives to enhance patient management and eventually decrease mortality.

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.

A Case of Left Ventricular Pseudoaneurysm as a Complication of Late-Presenting ST-Segment Elevation Myocardial Infarction

This case report delineates the clinical trajectory and management strategies of a 59-year-old Hispanic male diagnosed with a left ventricular pseudoaneurysm (LVPA) following a delayed presentation of ST-segment elevation myocardial infarction (STEMI), for which reperfusion treatment was not administered. Initially, an echocardiogram demonstrated an extensive anterolateral myocardial infarction, severe left ventricular systolic dysfunction, and an early-stage left ventricular apical aneurysm with thrombus, leading to the initiation of warfarin. Metabolic myocardial perfusion imaging via positron emission tomography indicated a substantial myocardial scar without viability, guiding the decision against revascularization. Post discharge, the patient, equipped with a wearable cardioverter defibrillator for sudden cardiac death prevention, experienced symptomatic ventricular tachycardia, which was resolved with defibrillator shocks. Subsequent imaging revealed an acute LVPA adjacent to the existing left ventricular aneurysm. Given the high surgical risk, conservative management was elected, resulting in thrombosis and closure of the pseudoaneurysm after two weeks. The patient eventually transitioned to home hospice, surviving an additional five months. This report underscores the complexities and therapeutic dilemmas in managing post-MI LVPA patients who are ineligible for surgical intervention.

Multicentre short- and medium-term report on the device closure of a post-myocardial infarction ventricular septal rupture - In search of risk factors for early mortality

BACKGROUND

Post-myocardial infarction ventricular septal rupture (VSR) is a rare and severe complication of myocardial infarction. To find early mortality (<30 days) risk factors of device VSR closure and to evaluate its medium-term outcome.

METHODS

Multicenter retrospective analysis on all 46 consecutive patients with percutaneous (n = 43) or hybrid (n = 3) VSR closure in 2000-2020 with various nitinol wire mesh occluders. Medical records, hemodynamic data, procedure results, short- and mid-term follow-up were analyzed (4.8 ± 3.7 years, range: 0.1-15, available in 61.7% of patients). Of the patients, 34.8% underwent VSR closure in acute phase (<21 days after VSR occurrence), 17.4% underwent device closure due to significant residual shunt after previous VSR surgery.

RESULTS

Success rate was 78.3%. More than moderate residual shunt, major complications, and early surgical reintervention affected 18.9%, 15.2% (including 2 intra-procedural deaths), and 21.7% of patients, respectively. Early mortality was 26.1% (13.9% in successful vs. 70% in unsuccessful closure; p < 0.001). Older age, need for intra-aortic balloon counterpulsation, severe complications, and procedural failure were identified as risk factors for early mortality. Among patients who survived the early period, the 5-year survival rate was 57.1%. NYHA class improved in 88.2% patients at the latest follow-up.

CONCLUSIONS

Procedure of VSR device closure demonstrates an acceptable technical success rate; however, the incidence of severe complications and early mortality is notably high. Older patients in poor hemodynamic condition and those with unsuccessful occluder deployment are particularly at a higher risk of a fatal outcome. The prognosis after early survival is promising.

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.

Development of a simple prediction model for mechanical complication in ST-segment elevation myocardial infarction patients after primary percutaneous coronary intervention

Mechanical complication (MC) is a rare but serious complication in patients with ST-segment elevation myocardial infarction (STEMI). Although several risk factors for MC have been reported, a prediction model for MC has not been established. This study aimed to develop a simple prediction model for MC after STEMI. We included 1717 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Of 1717 patients, 45 MCs occurred after primary PCI. Prespecified predictors were determined to develop a tentative prediction model for MC using multivariable regression analysis. Then, a simple prediction model for MC was generated. Age ≥ 70, Killip class ≥ 2, white blood cell ≥ 10,000/µl, and onset-to-visit time ≥ 8 h were included in a simple prediction model as "point 1" risk score, whereas initial thrombolysis in myocardial infarction (TIMI) flow grade ≤ 1 and final TIMI flow grade ≤ 2 were included as "point 2" risk score. The simple prediction model for MC showed good discrimination with the optimism-corrected area under the receiver-operating characteristic curve of 0.850 (95% CI: 0.798-0.902). The predicted probability for MC was 0-2% in patients with 0-4 points of risk score, whereas that was 6-50% in patients with 5-8 points. In conclusion, we developed a simple prediction model for MC. We may be able to predict the probability for MC by this simple prediction model.

Transcatheter edge-to-edge repair in papillary muscle injury complicating acute myocardial infarction

AIMS

Acute mitral regurgitation (MR) in the setting of myocardial infarction (MI) may be the result of papillary muscle rupture (PMR). This condition is associated with high morbidity and mortality. We aim to evaluate the feasibility of transcatheter edge-to-edge mitral valve repair (TEER) in this acute setting.

METHODS AND RESULTS

We analysed data from the International Registry of MitraClip in Acute Mitral Regurgitation following acute Myocardial Infarction (IREMMI) of 30 centres in Europe, North America, and the middle east. We included patients with post-MI PMR treated with TEER as a salvage procedure, and we evaluated immediate and 30-day outcomes. Twenty-three patients were included in this analysis (9 patients suffered complete papillary muscle rupture, 9 partial and 5 chordal rupture). The patients' mean age was 68 ± 14 years. Patients were at high surgical risk with median EuroSCORE II 27% (IQR 16, 28) and 20 out of 23 (87% were in cardiogenic shock). All patients were treated with vasopressors, and 17 out of 23 patients required mechanical support. TEER procedure was performed on the median 6 days after the index MI date IQR (3, 11). Procedural success was achieved in 87% of patients. The grade of MR was significantly decreased after the procedure. MR reduction to 0 or 1 + was achieved in 13 patients (57%), to 2 + in 7 patients (30%), P < 0.01. V-Wave was reduced from 49 ± 8 mmHg to 26 ± 10 mmHg post-procedure, P < 0.01. Sixteen out of 23 patients (70%) were discharged from hospital and 5 of them required reintervention with surgical mitral valve replacement. No additional death at 1 year was documented.

CONCLUSIONS

TEER is a feasible therapy in critically ill patients with PMR due to a recent MI. TEER may have a role as salvage treatment or bridge to surgery in this population.

1-Year Mortality Prediction through Artificial Intelligence Using Hemodynamic Trace Analysis among Patients with ST Elevation Myocardial Infarction

Background and Objectives: Patients presenting with ST Elevation Myocardial Infarction (STEMI) due to occlusive coronary arteries remain at a higher risk of excess morbidity and mortality despite being treated with primary percutaneous coronary intervention (PPCI). Identifying high-risk patients is prudent so that close monitoring and timely interventions can improve outcomes. Materials and Methods: A cohort of 605 STEMI patients [64.2 ± 13.2 years, 432 (71.41%) males] treated with PPCI were recruited. Their arterial pressure (AP) wave recorded throughout the PPCI procedure was analyzed to extract features to predict 1-year mortality. After denoising and extracting features, we developed two distinct feature selection strategies. The first strategy uses linear discriminant analysis (LDA), and the second employs principal component analysis (PCA), with each method selecting the top five features. Then, three machine learning algorithms were employed: LDA, K-nearest neighbor (KNN), and support vector machine (SVM). Results: The performance of these algorithms, measured by the area under the curve (AUC), ranged from 0.73 to 0.77, with accuracy, specificity, and sensitivity ranging between 68% and 73%. Moreover, we extended the analysis by incorporating demographics, risk factors, and catheterization information. This significantly improved the overall accuracy and specificity to more than 76% while maintaining the same level of sensitivity. This resulted in an AUC greater than 0.80 for most models. Conclusions: Machine learning algorithms analyzing hemodynamic traces in STEMI patients identify high-risk patients at risk of mortality.

Successful Suture-Free Repair of Left Ventricular Rupture Using the EVARREST Patch

Left ventricular free wall rupture is a lethal complication of myocardial infarction. Although emergent surgical repair is the treatment of choice, the method of repair remains highly individualized. This report presents a case of spontaneous coronary artery dissection in a patient with Turner syndrome that led to left ventricular free wall rupture and was successfully repaired on cardiopulmonary bypass using a suture-free technique with the EVARREST Fibrin Sealant Patch.

Proteomic analysis of plasma proteins from patients with cardiac rupture after acute myocardial infarction using TMT-based quantitative proteomics approach

BACKGROUND

Cardiac rupture (CR) is a rare but catastrophic mechanical complication of acute myocardial infarction (AMI) that seriously threatens human health. However, the reliable biomarkers for clinical diagnosis and the underlying signaling pathways insights of CR has yet to be elucidated.

METHODS

In the present study, a quantitative approach with tandem mass tag (TMT) labeling and liquid chromatography-tandem mass spectrometry was used to characterize the differential protein expression profiles of patients with CR. Plasma samples were collected from patients with CR (n = 37), patients with AMI (n = 47), and healthy controls (n = 47). Candidate proteins were selected for validation by multiple reaction monitoring (MRM) and enzyme-linked immunosorbent assay (ELISA).

RESULTS

In total, 1208 proteins were quantified and 958 differentially expressed proteins (DEPs) were identified. The difference in the expression levels of the DEPs was more noticeable between the CR and Con groups than between the AMI and Con groups. Bioinformatics analysis showed most of the DEPs to be involved in numerous crucial biological processes and signaling pathways, such as RNA transport, ribosome, proteasome, and protein processing in the endoplasmic reticulum, as well as necroptosis and leukocyte transendothelial migration, which might play essential roles in the complex pathological processes associated with CR. MRM analysis confirmed the accuracy of the proteomic analysis results. Four proteins i.e., C-reactive protein (CRP), heat shock protein beta-1 (HSPB1), vinculin (VINC) and growth/differentiation factor 15 (GDF15), were further validated via ELISA. By receiver operating characteristic (ROC) analysis, combinations of these four proteins distinguished CR patients from AMI patients with a high area under the curve (AUC) value (0.895, 95% CI, 0.802-0.988, p < 0.001).

CONCLUSIONS

Our study highlights the value of comprehensive proteomic characterization for identifying plasma proteome changes in patients with CR. This pilot study could serve as a valid foundation and initiation point for elucidation of the mechanisms of CR, which might aid in identifying effective diagnostic biomarkers in the future.

Delayed surgical repair via right ventricular approach with Impella and extracorporeal life support in post-myocardial infarction ventricular septal defect: A case report

INTRODUCTION

Post-myocardial infarction ventricular septal defect (PIVSD) is a life-threatening mechanical complication of acute myocardial infarction (AMI). Delayed elective surgical repair can be considered in patients who respond well to aggressive heart failure therapy. Impella has been reported as a bridge to allow the deferment of surgery for PIVSD.

PRESENTATION OF CASE

This report describes our case of a 62-year-old male with PIVSD and cardiogenic shock. Impella was placed to ensure hemodynamic stability. Subsequently, right heart failure was suspected to be caused by insufficient circulatory support from Impella alone. Emergency surgery was considered, but it was high risk and only a few days had passed since the onset. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted to treat right heart failure and delay surgical repair as long as possible. Six days after Impella implantation, the patient underwent a successful surgical repair via the right ventricle without associated adverse events.

DISCUSSION

Impella support can be insufficient for critically ill patients such as those with a larger ventricular septal defect and involvement of right ventricular function. VA-ECMO was implanted to support circulation, reduce the preload in the right ventricle, and avoid shunt inversion induced by increasing Impella flow. The patient was able to undergo a successful delayed repair with VA-ECMO at least one week after the onset of the AMI with hemodynamic stability and no associated adverse events.

CONCLUSION

Additional VA-ECMO could help patients who fail to bridge to surgery with Impella to avoid emergency surgery, leading to successful delayed surgical repair.

Structural Complications Following ST-Elevation Myocardial Infarction: An Analysis of the National Inpatient Sample 2016 to 2020

ST-elevation myocardial infarction (STEMI) is a life-threatening emergency that can result in cardiac structural complications without timely revascularization. A retrospective study from the National Inpatient Sample included all patients with a diagnosis of STEMI between 2016 and 2020. Primary outcomes of interest were in-hospital mortality, length of stay (LoS), and healthcare costs for patients with and without structural complications. There were 994,300 hospital admissions included in the analysis (median age 64 years and 32.2% female). Structural complications occurred in 0.78% of patients. There was a three-fold increase in patients with cardiogenic shock (41.6% vs. 13.6%) and in-hospital mortality (30.6% vs. 10.7%) in the group with structural complications. The median LoS was longer (5 days vs. 3 days), and the median cost was significantly greater (USD 32,436 vs. USD 20,241) for patients with structural complications. After adjustments, in-hospital mortality was significantly greater for patients with structural complications (OR 1.99, 95% CI 1.73-2.30), and both LoS and costs were greater. There was a significant increase in mortality with ruptured cardiac wall (OR 9.16, 95% CI 5.91-14.20), hemopericardium (OR 3.20, 95% CI 1.91-5.35), and ventricular septal rupture (OR 2.57, 95% CI 1.98-3.35) compared with those with no complication. In conclusion, structural complications in STEMI patients are rare but potentially catastrophic events.

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.