Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction

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.

Delayed Ventricular Septal Rupture Repair After Myocardial Infarction: An Updated Review

Ventricular septal rupture (VSR) is a rare but serious complication that can occur after myocardial infarction (MI) and is associated with significant morbidity and mortality. The optimal management approach for VSR remains a topic of debate, with considerations including early versus delayed surgery, risk stratification, pharmacological interventions, minimally invasive techniques, and tissue engineering. The pathophysiology of VSR involves myocardial necrosis, inflammatory response, and enzymatic degradation of the extracellular matrix (ECM), particularly mediated by matrix metalloproteinases (MMPs). These processes lead to structural weakening and subsequent rupture of the ventricular septum. Hemodynamically, VSR results in left-to-right shunting, increased pulmonary blood flow, and potentially hemodynamic instability. The early surgical repair offers the advantages of immediate closure of the defect, prevention of complications, and potentially improved outcomes. However, it is associated with higher surgical risk and limited myocardial recovery potential during the waiting period. In contrast, delayed surgery allows for a period of myocardial recovery, risk stratification, and optimization of surgical outcomes. However, it carries the risk of ongoing complications and progression of ventricular remodeling. Risk stratification plays a crucial role in determining the optimal timing for surgery and tailoring treatment plans. Various clinical factors, imaging assessments, scoring systems, biomarkers, and hemodynamic parameters aid in risk assessment and guide decision-making. Pharmacological interventions, including vasopressors, diuretics, angiotensin-converting enzyme inhibitors, beta-blockers, antiplatelet agents, and antiarrhythmic drugs, are employed to stabilize hemodynamics, prevent complications, promote myocardial healing, and improve outcomes in VSR patients. Advancements in minimally invasive techniques, such as percutaneous device closure, and tissue engineering hold promise for less invasive interventions and better outcomes. These approaches aim to minimize surgical morbidity, optimize healing, and enhance patient recovery. In conclusion, the management of VSR after MI requires a multidimensional approach that considers various aspects, including risk stratification, surgical timing, pharmacological interventions, minimally invasive techniques, and tissue engineering.

Late Presentation of Acute Coronary Syndrome Complicated by Ventricular Septal Rupture

Acquired ventricular septal rupture (VSR) is a rare but potentially fatal complication of late-presenting myocardial infarction (MI). In the era of revascularization and reperfusion therapy, the incidence of VSR has significantly decreased. Ruptures occur predominantly in patients with late-presenting ST elevation MI. Patients may present with a wide variety of symptoms ranging from chest pain and mild hemodynamic instability to profound cardiogenic shock. Inotropes, vasopressors, and mechanical support with intra-aortic balloon pumps and extracorporeal membrane oxygenation can be used to bridge patients to surgery. Despite treatment with ventricular septal repair, postsurgical mortality remains high. There is a wide variety of complications that can occur in the postoperative period. A multidisciplinary approach is vital in these patients who develop VSR. Improving awareness among healthcare professionals regarding the symptoms of acute coronary syndrome can hopefully help prevent delayed presentation of patients to healthcare facilities.

Mechanical Complications of Myocardial Infarction

Mechanical complications of myocardial infarction include rupture of a papillary muscle, ventricular septum, and free wall. Since the advent of acute coronary reperfusion, there has been a significant reduction in the incidence of these complications. One must have a high index of suspicion for a mechanical complication in any patient who develops cardiogenic shock in the days following a myocardial infarction. The most important diagnostic investigation in evaluation of these complications is echocardiography. Although there is a role for mechanical circulatory support, urgent surgical repair is required in most cases. We will review the predictors, clinical features, diagnostic, and management strategies in patients with these complications.

Ventricular Septal Rupture Following Acute Myocardial Infarction

ST-segment elevation myocardial infarction (STEMI) is a known medical exigency that has seen considerable advances in medical treatment, dramatically boosting survival rates. Post myocardial infarction ventricular rupture is a major serious mechanical complication following myocardial infarction. We present a case of a 68-year-old male admitted to the emergency department with heaviness in the chest, for which electrocardiography was done and it was suggestive of anterior and lateral wall myocardial infarction. After six hours he experienced breathlessness, jugular venous pressure (JVP) was raised, and auscultation revealed early systolic murmur at apex suggestive of ventricular septal rupture. An urgent echocardiogram was done and it confirmed the diagnosis of ventricular septal rupture (VSR). To enhance the prognosis, early identification and appropriate care are required, which necessitate a thorough clinical evaluation that raises the possibility of mechanical problem, as late presentation is one of the major risk factors for developing VSR. VSR can manifest itself in numerous ways, based on the patient's condition. Right clinical judgement and ECG are required to establish a quick diagnosis, as a result, to determine the most appropriate treatment at the appropriate time.

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.

Management of ST-Elevation Myocardial Infarction in High-Risk Settings

Despite the widespread adoption of primary percutaneous intervention and modern antithrombotic therapy, ST-segment elevation myocardial infarction (STEMI) remains the leading cause of death in the United States and remains one of the most important causes of morbidity and mortality worldwide. Certain high-risk patients present a challenge for diagnosis and treatment. The widespread adoption of primary percutaneous intervention in addition to modern antithrombotic therapy has resulted in substantial improvement in the short- and long-term prognosis following STEMI. In this review, we aim to provide a brief analysis of the state-of-the-art treatment for patients presenting with STEMI, focusing on cardiogenic shock, current treatment and controversies, cardiac arrest, and diagnosis and treatment of mechanical complications, as well as multivessel and left main-related STEMI.

Echocardiography in Detecting Mechanical Complications in Acute Coronary Syndrome

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ACS encompasses a wide variety of complex symptoms and presentations.

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The use of echocardiography in ACS assists in early clinical decision-making.

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Echocardiography can aid in detecting early and late mechanical complications of ACS.

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Early detection of complications of ACS on echocardiography can improve outcomes.

Outcomes of Early Versus Delayed Transcatheter Closure of Post-Myocardial Infarction Ventricular Septal Defect

BACKGROUND

Post myocardial infarction ventricular septal defect (VSD) is a rare, but devastating complication which carries a poor prognosis if left untreated. Optimal therapy remains unclear and surgical repair is associated with high mortality.

OBJECTIVE

The aim of our study is to compare 30-day survival in patients with early versus late primary transcatheter repair of post myocardial infarction ventricular septal defect.

METHODS

We performed a comprehensive search of published data through SCOPUS and identified published reports of primary transcatheter closure of post myocardial infarction VSD. We included case reports and series that reported timing of VSD closure and 30-day survival and excluded those with prior surgical repair. Early repair was defined as transcatheter closure within 14 days of diagnosis of VSD while late repair was defined as transcatheter closure after 14 days of diagnosis of VSD.

RESULTS

A total 27 publications describing 193 patients were identified in the SCOPUS search. We excluded 8 publications with no reported timing of VSD repair or 30-day outcome. Of the 193 patients initially included, a total of 126 patients fulfilled all the criteria and were included in the final analysis. The overall 30-day survival rate was found to be 62.7% (79 patients). In the early repair group, only 36.2% of the patients were still alive at 30 days compared to 85.3% in the delayed repair group, P < .01. No significant difference in age, gender, presence of shock, VSD size, presence of significant residual shunt, location of VSD or infarction was observed. The early repair group was found to have a significantly larger Qp: Qs ratio as well as larger occluder size and lower rate of successful repair.

CONCLUSION

Compared to the late repair group, the early transcatheter VSD repair group had a larger pre-procedure Qp:Qs and worse 30-day survival. Further studies are needed to determine the optimal timing of transcatheter repair of a post myocardial infarction VSD.

Echocardiographic assessment of mitral regurgitation

Mitral regurgitation (MR) is one of the most frequent indications for valve surgery in developed countries, and echocardiographic assessment is an essential tool to evaluate its etiologies, severity, and therapeutic indications. The mitral valve apparatus is a complex structure composed of several parts: apart from the mitral valve leaflets and annulus, it also includes the chordae tendineae, papillary muscles, and left ventricular (LV) wall. MR can be caused not only by organic changes of the mitral valve leaflets or chordae (primary MR) but also by extreme mitral annular enlargement or mitral leaflet tethering due to displacement and malfunction of papillary muscles and LV wall (secondary MR). In secondary MR with LV dysfunction, a milder degree of MR can be associated with adverse outcomes compared with primary MR. Grading the severity is the first step in evaluation of indication for surgical/transcatheter interventions. As such, there are several techniques to assess the severity of MR using echocardiography. However, none of the techniques is reliable enough by itself, and it is always recommended to integrate multiple methods. In cases where echocardiographic assessment of MR severity is inconclusive, magnetic resonance may be helpful. In addition to the severity, anatomical information, such as localization in primary MR due to mitral valve prolapse and LV size in secondary MR due to LV dilatation/dysfunction, is an important concern in presurgical echocardiography. Transesophageal echocardiography and three-dimensional echocardiography are key techniques for anatomical evaluation including mitral valve and LV volumes. In transcatheter intervention for MR, echocardiography plays a pivotal role as a guide for procedures and endpoints. In this review article, the authors provide a comprehensive summary of current standards of echocardiographic assessment of MR.

Ventricular septal rupture presented with chronic heart failure symptoms: a case report

BACKGROUND

Ventricular septal rupture (VSR) is a rare mechanical complication following acute myocardial infarction, with very high mortality rate. Haemodynamic deterioration and cardiogenic shock is common in such cases. Rarely, however, patients may show only signs of chronic heart failure or be completely asymptomatic.

CASE SUMMARY

We report a case of a 72-year-old male patient with VSR following a transmural myocardial infarction. He sought medical attention only after gradually experiencing symptoms of chronic heart failure, weeks after the onset of the myocardial infarction. The patient successfully underwent elective repair surgery, after optimizing the medical therapy and completing the necessary workup.

DISCUSSION

Ventricular septal rupture repair is necessary in all cases due to the high mortality rate if left untreated. The timing of the operation, however, should be decided individually for every patient. Haemodynamically unstable patients may require early surgery, but in stable patients responding to medical treatment, delayed repair may be the best option.

Ventricular septal rupture following myocardial infarction: A potentially fatal complication

Mechanical complications of acute myocardial infarction include ventricular septal rupture (VSR), free wall rupture, and ischemic mitral regurgitation. Postinfarction VSR is a rare but serious complication of myocardial infarction. VSR has a lower incidence in the era of new reperfusion therapies. However, clinicians should be aware of this potentially fatal complication as the mortality remains extremely high. Early diagnosis and treatment are the cornerstones of achieving a better outcome.

Post-Myocardial Infarction Ventricular Septal Defect: A Comprehensive Review

Post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but potentially catastrophic mechanical complication that occurs in <1% of patients following a myocardial infarction and it is associated with a high morbidity and mortality despite improvements in medical and surgical therapies. Post-MI VSD is a medical emergency and outcome is very poor in medically treated patients. Treatment of choice remains surgical closure of defect and transcatheter defect closure less so. We performed a comprehensive review of the clinical presentation and management options of post-MI VSD.

Utility of cardiac MRI in determining percutaneous versus surgical post-infarction ventricular septal defect repair

AIM

Postmyocardial infarction ventricular septal defect (VSD) is a rare complication that can lead to rapid hemodynamic patient decompensation. The type of VSD repair relies on several factors including: size, location, timing and surgical expertise.

CASE

A 63-year-old man with a ST-elevation myocardial infarction underwent percutaneous coronary intervention of the right coronary artery. A holosystolic murmur was notable postcatheterization, and transthoracic echocardiogram confirmed a VSD. To characterize the VSD, a cardiac MRI demonstrated a large, serpiginous VSD and longitudinal septal tear. Given the anatomic complexity and stable hemodynamics, a surgical trans-left ventricular patch repair was performed.

CONCLUSION

We emphasize the importance of cardiac magnetic resonance as a decision-making tool, utilizing imaging to ascertain the anatomy combined with hemodynamics to determine optimal individualized therapy.

Heart Failure Complicating Acute Mtyocardial Infarction

Factors predisposing the older person with acute myocardial infarction (MI) to develop heart failure (HF) include an increased prevalence of MI, multivessel coronary artery disease, decreased left ventricular (LV) contractile reserve, impairment of LV diastolic relaxation, increased hypertension, LV hypertrophy, diabetes mellitus, valvular heart disease, and renal insufficiency. HF associated with acute MI should be treated with a loop diuretic. The use of nitrates, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone antagonists, beta-blockers, digoxin, and positive inotropic drugs; treatment of arrhythmias and mechanical complications; and indications for use of implantable cardioverter-defibrillators and cardiac resynchronization is discussed.

Minimization of door-to-balloon time for ST-elevation acute myocardial infarction: a case report

It is of utmost importance to minimize the door‐to‐balloon time for the initial treatment of ST‐elevation acute myocardial infarction. In this case report, we made all kinds of efforts to minimize procedures in the emergency department (ED minimization) as well as in the catheter laboratory without sacrificing safety.

The Role of Echocardiography in Acute Myocardial Infarction

The indications for echocardiography in the setting of acute myocardial infarction are to identify wall motion abnormalities, to evaluate left and right ventricular function, and to exclude complications such as pericarditis, mitral regurgitation, and ventricular rupture. Doppler echocardiography can provide important hemodynamic information. In the near future, contrast echocardiography can be expected to delineate myocardial perfusion and three-dimensional echocardiography to better define infarct size.

Delayed closure of postinfarction ventricular septum defect in a patient with single vessel disease

A 65-year-old patient with a systolic murmur that developed five days after acute anteroseptal myocardial infarction was referred to our Institution. He had previously been treated with fibrinolytic therapy. The patient was in a stable hemodynamic condition when admitted, with sustained diuresis. Blood gas analysis revealed normal parameters, whereas a chest X-ray showed signs of pulmonary congestion. Transthoracic echocardiography revealed a 1.5×1.2 cm post-infarction ventricular septum defect (VSD) in the apical part of the septum. Because the patient’s hemodynamic conditions were stable, we decided to postpone the operative treatment to allow scarring of the infarcted area to make VSD repair feasible, thereby increasing the chance for success. Operative treatment was performed three weeks after admission. We performed closure of the VSD with a bovine pericardial patch. The patient was discharged in good condition and remained well three months after the surgery.

Multimodality cardiac imaging of a ventricular septal rupture post myocardial infarction: a case report

Background

Ventricular septal rupture (VSR), a mechanical complication following an acute myocardial infarction (MI), is thought to result from coagulation necrosis due to lack of collateral reperfusion. Although the gold standard test to confirm left-to-right shunting between ventricular cavities remains invasive ventriculography, two-dimensional transthoracic echocardiography (TTE) with color flow Doppler and cardiac MRI (CMR) are reliable tests for the non-invasive diagnosis of VSR.

Case presentation

A 62-year-old Caucasian female presented with a late case of a VSR post inferior MI diagnosed by multimodality cardiac imaging including TTE, CMR and ventriculography.

Conclusion

We review the presentation, diagnosis and management of VSR post MI.

Post myocardial infarction cardiogenic shock: a review of current therapies

Cardiogenic shock is often a devastating consequence of acute myocardial infarction (MI) and portends to significant mortality and morbidity. Despite improvements in expediting the time to treatment and enhancements in available medical therapy and reperfusion techniques, cardiogenic shock remains the most common cause of mortality following MI. Post-MI cardiogenic shock most commonly occurs as a consequence of severe left ventricular dysfunction. Right ventricular (RV) MI must also be considered. Mechanical complications including acute mitral regurgitation, ventricular septal rupture, and ventricular free-wall rupture can also lead to cardiogenic shock. Rapid diagnosis of cardiogenic shock and its underlying cause is pivotal to delivering definitive therapy. Intravenous vasoactive agents and mechanical support devices may temporize the patient's hemodynamic status until definitive therapy by percutaneous or surgical intervention can be performed. Despite prompt management, post-MI cardiogenic shock mortality remains high.

The vital role of papillary muscles in mitral and ventricular function: echocardiographic insights

The two left ventricular (LV) papillary muscles are small structures but are vital to mitral valve competence. Partial or complete rupture, complicating acute myocardial infarction, causes severe or even catastrophic mitral regurgitation, potentially correctable by surgery. Papillary muscle dysfunction is a controversial topic in that the role of the papillary muscle itself, in causing mitral regurgitation post infarction, has been seriously questioned; it is less confusing if this syndrome is attributed not only to papillary muscle but also to adjacent LV wall ischemia or infarction. Papillary muscle calcification is easily and frequently detected on echocardiography, but its clinical significance remains uncertain. Papillary muscle hypertrophy accompanies LV hypertrophy of varied etiology and may have a significant role in producing dynamic late-systolic intra-LV obstruction in hypertrophic cardiomyopathy and other hyperdynamic hypertrophied LV chambers. All the above abnormalities can be adequately assessed by 2-D echocardiography and the Doppler modalities. In selected cases, transesophageal echocardiography can provide additional valuable data by improving visualization of papillary muscles and mitral apparatus.

Imaging studies in patients with heart failure: current and evolving technologies

Technological advances continue to expand the clinical role of echocardiography in the intensive care unit, particularly in patients with heart failure. It has many advantages over tomographic techniques such as echo cardiac magnetic resonance imaging and cardiac computed tomography, can provide rapid bedside cardiac assessment, and facilitate emergent decision-making for critically ill patients. Image quality problems in the intensive care setting have largely been overcome by the use of harmonic imaging, contrast opacification, and when indicated, transesophageal echocardiography. Newer techniques promise to advance the scope and prognostic power of echocardiography, and to expand the portability and availability of this tool.

Heart Failure–Complicating Acute Myocardial Infarction

This article addresses issues related to acute myocardial infarction (MI) complicated by heart failure, particularly in elderly patients. Findings have shown that acute MI complicated by congestive heart failure (CHF) is associated with a high mortality, and that women with acute MI are more likely to be older and to develop CHF than men with acute MI. In general, management of CHF complicating acute MI is similar in older and younger patients. Actions discussed include hemodynamic monitoring; the administration of oxygen; and the use of morphine, diuretics, nitroglycerin, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, spironolactone, beta-blockers, calcium channel blockers, magnesium, digoxin, and positive inotropic drugs. The article also discusses measures for treating arrhythmias and for diagnosing mechanical complications.

Heart-Failure–Complicating Acute Myocardial Infarction

This article addresses issues related to acute myocardial infarction(MI) complicated by heart failure, particularly in elderly patients. Findings have shown that acute MI complicated by congestive heart failure (CHF) is associated with a high mortality, and that women with acute MI are more likely to be older and to develop CHF than men with acute MI. In general, management of CHF-complicating acute MI is similar in older and younger patients. Actions discussed include hemodynamic monitoring; the administration of oxygen; and the use of morphine, diuretics, nitroglycerin,angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, spironolactone, beta-blockers, calcium channel blockers, magnesium, digoxin, and positive inotropic drugs. The article also discusses measures for treating arrhythmias and for diagnosing mechanical complications.

Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction

Ventricular septal rupture (VSR), which can complicate an acute myocardial infarction (MI), carries a high mortality rate. Because precordial and transesophageal echocardiography can identify the type of rupture and assess right ventricular (RV) function at the patient's bedside, we examined the prognostic significance of echocardiographic patterns in postinfarct VSR by postulating that complex rupture and RV involvement carry a worse prognosis. Seventeen patients (10 men; mean age 66 years) who had confirmed postinfarct VSR underwent precordial and transesophageal echocardiography followed by coronary angiography. Serial 12-lead and right precordial leads were also available. Type of septal rupture was classified as simple or complex based on autopsy-proved echocardiographic criteria. Three patients had inferior wall MI and 14 had anterior wall MI. ST-segment elevation persisted >72 hours in all 3 patients who had inferior wall MI and in 12 who had anterior wall MI. Segmental wall motion abnormalities helped in detecting the left ventricular entry site, and use of unconventional views superimposed with color flow Doppler provided the RV exit site. RV function was better appreciated with transesophageal echocardiography. Two patients who had inferior wall MI and 7 who had anterior wall MI had complex ruptures. All 3 patients who had inferior wall MI and 7 who had anterior wall MI had electrocardiographic and echocardiographic evidence of RV involvement. Mortality rate was higher in patients who had complex rupture (78% vs 38%, p <0.001) and in those who had RV extension (71% vs 29%, p <0.001). In conclusion, persistent ST elevation is a common finding in patients who have postinfarct VSR. Complex VSR and RV involvement are significant determinants of clinical outcome.

Acute myocardial infarction: disposition to the operating room?

Given their low incidence, mechanical complications of AMI represent a diagnostic and therapeutic challenge for the EP. When the panoply of medical interventions has reached its limitation, surgical treatment plays a role in the management of the patient who has AMI. For patients who have CS and severe compromise of myocardial reserve, surgical intervention might represent the only means of restoring blood flow to the myocardium. For patients who have mechanical complications, correction of the defect before the onset of terminal organ failure might provide long-term survival.

Heart failure complicating acute myocardial infarction

Older people with congestive heart failure associated with acute myocardial infarction should be treated with loop diuretic therapy. Class I indications for the use of early intravenous beta blockade in patients with acute myocardial infarction are patients without a contraindication to beta blockers who can be treated within 12 hours of onset of myocardial infarction; patients with continuing or recurrent ischemic pain; and patients with tachyarrythmias, such as atrial fibrillation with a rapid ventricular rate. Class I indications for the use of angiotensin-converting enzyme inhibitors during acute myocardial infarction are (1) patients within the first 24 hours of onset of a suspected acute myocardial infarction with ST segment elevation in two or more anterior precordial leads or with clinical heart failure in the absence of significant hypotension or contraindications to the use of angiotensin-converting enzyme inhibitors, (2) patients with myocardial infarction and a left ventricular ejection fraction of less then 40%, (3) and patients with clinical heart failure on the basis of systolic pump dysfunction during and after convalescence from acute myocardial infarction. No class I indications exist for using calcium channel blockers or magnesium during acute myocardial infarction.

Role of Echocardiography in Complications Associated with Partial or Complete Rupture of the Myocardium in Acute Myocardial Infarction

In this report, we focus on the specific complications of acute myocardial infarction that are associated with rupture of the myocardium and for which two-dimensional and Doppler color flow echocardiography expedites accurate diagnosis for prompt treatment, including surgical repair, which can be crucial to survival in such cases.

Echocardiography's Role in Cardiogenic Shock After Acute Myocardial Infarction

Cardiogenic shock is an emergent condition that requires immediate diagnosis. Assessment and evaluation of potential complications that often accompany shock must also be made. These complications may be seen individually or in concert. Echocardiography has emerged in the last two decades as the single most important procedure in this effort. The authors reviewed four cases of cardiogenic shock after acute myocardial infarction: two with ventricular septal rupture, one with papillary muscle rupture, and one with severe global left ventricular dysfunction. Each patient was evaluated emergently with echocardiography. Results were compared with electrocardiography, arteriography, right heart catheterization studies, and surgical reports.

[A case of emergency surgery for acute mitral regurgitation due to complete papillary muscle rupture as complication of acute inferior myocardial infarction]

We experienced a case with acute mitral regurgitation caused by complete posterior papillary muscle rupture as complication of acute inferior myocardial infarction, who underwent successfully emergency operation of mital valve replacement and coronary revascularization in acute stage. A 64-year-old woman developed sudden cardiogenic shock shortly after the onset of acute inferior myocardial infarction. The diagnosis of acute inferior myocardial infarction was based on the electrocardiographic findings. Under IABP support, preoperative coronary angiography visualized total occlusion of segment 3 of the right coronary artery, and preoperative left ventriculography showed akinesis of inferior wall and severe mitral regurgitation. At 6 hours after onset of papillary muscle rupture, emergency operation was performed. At operation, posterior papillary muscle was found to be totally ruptured. Coronary artery revascularization and mitral valve replacement were performed. Postoperative course was uneventful, with 4 days of IABP and 5 days of ventilatory support. She was discharged on the twentieth postoperative day in NYHA class I. Reports of successful emergency operation for total papillary muscle rupture following acute myocardial infarction are rare. Early diagnosis and surgical treatment are mandatory to save this group of patients.

Repair of postinfarction ventricular septal defects

Postinfarction ventricular septal defects complicate approximately 1% to 2% of cases of acute myocardial infarction and account for about 5% of early deaths after myocardial infarction. By differentiating the surgical treatment of these acquired lesions from the surgical approaches used to repair congenital ventricular septal defects and realizing the significance of differing anatomic locations of postinfarction ventricular septal defects, techniques have been developed that have improved salvage of patients suffering this catastrophic complication of myocardial infarction. The principles underlying these surgical techniques include (1) expeditious establishment of total cardiopulmonary bypass with moderate hypothermia and meticulous attention to myocardial protection; (2) transinfarct approach to ventricular septal defect with the site of ventriculotomy determined by the location of the transmural infarction; (3) thorough trimming of the left ventricular margins of the infarct back to viable muscle to prevent delayed rupture of the closure; (4) conservative trimming of the right ventricular muscle as required for complete visualization of the margins of the defect; (5) inspection of the left ventricular papillary muscles and concomitant replacement of the mitral valve only if there is frank papillary muscular rupture; (6) closure of the septal defect without tension, which in most instances will require the use of prosthetic material; (7) closure of the infarctectomy without tension with generous use of prosthetic material as indicated, and epicardial placement of the patch to the free wall to avoid strain on the friable endocardial tissue; and (8) buttressing of the suture lines with pledgets or strips of Teflon felt or similar material to prevent sutures from cutting through friable muscle.

Echocardiographic Features of Ventricular Septal Rupture with Right Ventricular Aneurysm After Acute Myocardial Infarction

Postinfarction ventricular septal defect is a life-threatening disorder that may be adequately treated if the diagnosis is obtained promptly. Two-dimensional color Doppler echocardiography is a reliable tool for this diagnosis and gives additional information regarding its location, size, and shape. The authors emphasize the feasibility of this method to depict a particular form of postinfarction interventricular septal rupture, which developed an aneurysm inside the right ventricular cavity. Its characteristics were completely defined by color Doppler echocardiography and confirmed at surgery. (ECHOCARDIOGRAPHY, Volume 13, May 1996)

Emergent use of echocardiography in a post-myocardial infarction patient with acute dyspnea

Acute dyspnea in a post-myocardial infarction patient may prompt the physician to use further diagnostic testing to evaluate apparent worsening left ventricular function, ischemia, mitral valve dysfunction, chordae or valvular rupture, or a ventricular septal defect producing a left to right shunt. We present a case of a 62-year-old woman with an unrecognized myocardial infarction at home who presented to the emergency department (ED) acutely dyspneic and free of chest pain. Prompt evaluation in the ED with echocardiography and Doppler imaging proved time-efficient and allowed early lifesaving surgery to be performed. We propose that access to emergent echocardiography in select cases should be a standard service in every ED.

Good long-term outcome following surgical repair of post-infarction ventricular septal defect

BACKGROUND

A post-infarction ventricular septal defect (VSD) is a serious complication of a myocardial infarction with 90% of patients dying by two months, in published series. Urgent surgical repair improves the prognosis.

AIMS

To assess the Green Lane Hospital experience over a ten year period, especially with regard to hospital mortality and long-term follow up.

METHODS

A retrospective case note review of all 35 consecutive patients undergoing post-infarct VSD repair from 1981 to 1990. Long-term follow up was obtained in all but one patient (97%).

RESULTS

Twenty-one male and 14 female patients presented with a mean age of 67 years (range 51-75). All were in NYHA class 3 or 4, 14 (40%) were in cardiogenic shock. Following urgent surgical repair, 30 day mortality was 31% (11 patients). A further three patients died at two, 33 and 39 months; one patient was lost to follow up. At a mean follow up of 61 months (range 16-111), 15 patients were in NYHA class 1 or 2, five in NYHA class 3 or 4. For the whole group (n = 35) the actuarial survival was 66% at one year, 62% at three years and 58% at nine years.

CONCLUSION

Post-infarct VSD surgery is of major prognostic benefit with patients obtaining a good long-term outcome.

Techniques and results of mitral valve repair for ischemic mitral regurgitation

Mitral regurgitation (MR) may start during the acute phase of myocardial infarction and it may increase, decrease, or remain unchanged as the necrotic muscle is replaced by fibrous tissue and remodeling of the ventricle takes place. Acute infarction can cause MR because of rupture of papillary muscle (PM) head or dysfunction of the PM and underlying ventricular wall. When MR is due to rupture of a single PM head and the surrounding muscle is not extensively infarcted, it is possible to suture the PM head in place with pledget sutures or to use other techniques of repair of flair leaflets such as chordal transfer or chordal replacement. When MR is due to extensive necrosis of the PM and the ventricular wall, it is safer to replace the mitral valve with preservation of the chordae tendineae. Correction of MR by means of valve repair in patients with healed myocardial infarction is frequently possible when the cause of MR is determined by Doppler echocardiography. The most common cause of MR is incomplete closure of the mitral valve due to apical displacement of the PM. Prolapse of the leaflets is rare in patients with healed myocardial infarction. Mitral annuloplasty decreases or abolishes MR in most cases when lack of coaptation of the leaflets is the problem. Transient ischemia can also cause MR. Successful myocardial revascularization either by angioplasty or coronary artery bypass often cures episodic ischemic MR.