In-hospital outcomes of mechanical complications in acute myocardial infarction: Analysis from a nationwide Spanish database

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.

Is pulmonary hypertension protective against cardiac tamponade? A systematic review

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

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.

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.

Predictors, Outcomes and Impact of Mechanical Circulatory Support of Patients With Mechanical Complications After Acute Myocardial Infarction

BACKGROUND

Despite early and currently effective epicardial coronary recanalization, the mortality rate after mechanical complication (MC) remains high, especially in cardiogenic shock. There is an increase in the use of mechanical circulatory support in patients with cardiogenic shock and MC, however, evidence is still scarce and most studies exclude patients with mechanical complications.

METHODS

Using the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the predictors and outcomes of patients with MC, subtypes and the use of MCS.

RESULTS

We identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC and of them 1320 (56.3 %) received MCS. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture (FWR). Mortality was 12 times higher (OR: 11.663, CI: 10.582-12.855, p < 0.001) in patients with MC compared to patients without MC (49.7 % vs. 4.6 %, p < 0.001) and all subtypes of MC showed a significant increase in mortality. The use of MCS was associated with decreased mortality in PMR (46.2 % to 34.8 %, p = 0.009) and pseudoaneurysm (64.7 % to 42.1 %, p < 0.001), however, with higher mortality in VSR.

CONCLUSIONS

The incidence of MC after an AMI is very low, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and with fewer comorbidities. The subtype with the highest frequency and highest mortality was VSR. The use of mechanical circulatory support was associated with better survival in PMR and pseudoaneurysm, but not overall survival.

Ventricular septal defect complicating myocardial infarction: A case of delayed percutaneous transcatheter closure

A 57-year-old man suffered chest pain during the COVID-19 pandemic, but he delayed medical treatment due to fear of infection. After 4 months, symptoms of chest tightness and shortness of breath appeared. Electrocardiogram (ECG) revealed old myocardial infarction; color sonography and myocardial computed tomography revealed apical myocardial defect. He refused surgery and percutaneous transcatheter closure, and follow-up observation. After 22 months, the symptoms of chest tightness and shortness of breath aggravated. He recovered after percutaneous transcatheter closure, and was discharged. This case shows delayed closure is one of the possible options for patients without severe organ dysfunction or hemodynamic disturbance.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trends in Ischemic Mitral Regurgitation Following ST-Elevation Myocardial Infarction Over a 20-Year Period

Background: Ischemic mitral regurgitation (IMR) is a common complication of acute ST-elevation myocardial infarction (STEMI). Little is known regarding the impact of IMR over a long period of follow up.

Methods: Of 3,208 consecutive STEMI patients from a prospective registry, full echocardiographic information was available for 2,985 patients between the years 2000 and 2020. We compared the two decades- 2001 to 2010 and 2011 to 2020, and assessed for the presence of IMR at baseline, 3 (range 2–6) months and 12 (range 10–14) months after the index event.

Results: One thousand six hundred and sixty six patients were included in the first decade, 1,319 in the second. Mean patient age was 61.3 ± 12.3 years, 21.1% female patients in the first decade vs. 60.9 ± 12.0 years and 22.2% female in the second (p = 0.40 and p = 0.212, respectively). Rates of moderate IMR or above during the index admission were 17.2% in the first period and 9.3% in the second one (p < 0.001). After 3 months, the rate of IMR was 48.5% for those who suffered from IMR at baseline, vs. 9.5% for those without IMR at baseline (HR- 4.2, p < 0.001). Death rates for those with moderate IMR or above were 14.7% and 17.8% after 1 and 2 years, respectively, vs. 7.3 and 9.6% for those without (p < 0.001 for both). IMR was associated with 1 year mortality in multivariate analysis (HR-1.37; 1.09–2.20, p = 0.009), as well as in propensity score matched analysis (HR 1.29; CI: 1.07–1.91; p < 0.001).

Conclusions: IMR is a common complication following acute STEMI, impacting prognosis. Rates of IMR have declined significantly over the years.

[Mechanical complications after myocardial infarction in a National Reference Hospital]

Objective

To determine the clinical characteristics, therapeutic and in-hospital mortality of patients with mechanical complications post myocardial infarction.

Materials and methods

Observational, descriptive and retrospective study. We included patients >18 years old with a diagnosis of mechanical complication post myocardial infarction hospitalized at the Instituto Nacional Cardiovascular- INCOR in Lima -Peru, from January 1, 2017 to December 31, 2021. Variables like clinical characteristics, treatments, complications, and in-hospital mortality were studied.

Results

We found 37 cases, with a predominance of males (73.0%) and a median age of 73 years old. The location of the myocardial infarction was 51.4% in the anterior wall and 43.2% in the inferior wall. The patients received reperfusion therapy with fibrinolysis in 5 cases (13.5%), coronary angioplasty in 5 (13.5%), and 73% received only medical management prior to the diagnosis of mechanical complications. Of the 37 patients, 13 (35.1%) presented isolated ventricular free wall rupture, 12 (32.4%) isolated interventricular septum rupture, 10 (27.0%) the combination of ventricular free wall rupture and interventricular septum, and 2 (5.4%) papillary muscle rupture. In-hospital mortality was 51.4%.

Conclusions

The ventricular free wall rupture was the most frequent complication, patients with mechanical complications after myocardial infarction still maintain high intra-hospital mortality rates, mainly in those who did not have adequate surgical treatment.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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