Right Ventricular Free Wall Rupture Due to Displaced Automatic Implantable Cardioverter Defibrillator (AICD) Lead

The implantation of an implantable cardioverter defibrillator (ICD) carries a risk for major complications, one of which is ventricular free wall rupture secondary to a lead perforation. This known complication, although rare, has estimated incidence rates between 0.1% and 3%. Predictive factors of such an event include temporary leads, steroid use, active fixation leads, low body mass index (<20 kg/m2), age greater than 80 years, female gender, and concurrent anticoagulation. Right ventricular systolic pressure >35 mmHg is considered a protective factor likely due to associated right ventricular hypertrophy. We present a case of a 73-year-old female with a history of aortic stenosis status post-transcatheter aortic valve replacement (TAVR) and atrial fibrillation (AFib) who met the criteria for an ICD after suffering ventricular fibrillation arrest (after TAVR procedure) ultimately resulting in lead perforation.

Sutureless repair of subacute left ventricular free wall rupture

Left ventricular free wall rupture (LVFWR) is one of the most lethal heart conditions where mortality rates reach 40% intraoperatively and 80% in hospital. A few days after the acute event, the rupture becomes subacute, and surgery is indicated to repair the frail myocardium. Despite the lack of strong evidence to support the efficacy of sutureless repair of subacute LVFWR in the literature, this technique has recently been gaining popularity with acceptable success rates. In this article, we present two techniques to repair the subacute LVFWR without using sutures: the direct glued-hemostatic patch technique and the glued pericardial patch technique. In both techniques, the healthy myocardium surrounding the infarcted zone is recruited, together with hemostatic materials, to seal the rupture. Moreover, we describe the clinical presentation of the acute and subacute LVFWR, peri-operative management, together with intra-operative tips and the advantages and disadvantages of each material used in these operations.

Rare survival of left ventricular free wall rupture following myocardial infarction

Myocardial free wall rupture is a rare but usually fatal complication of acute myocardial infarction (MI) especially if it occurs out of hospital and occurs in 2-4% of patients who suffer from acute MI. Rapid diagnosis is essential but not always easy as diagnostic tests may be inconclusive. In this case report authors examine a rare and unique patient survival after left ventricular free wall rupture following MI. The patient developed chest pain and hypotension in the hospital and was taken directly to the catheterization laboratory where a diagnostic angiogram showed a high-grade occlusion of a very small marginal branch, fluoroscopy demonstrated a large pericardial effusion, which was drained then auto transfused back to the patient using a femoral vein sheath. Rapid diagnostic testing including transesophageal echocardiography with Definity, transthoracic echocardiography, aortography and left ventriculography were all negative for dissection and rupture. Despite the negative diagnostic test, a high index of suspicion for rupture led to urgent surgical exploration where a large 4-cm hole was found in the lateral wall. Repair was successful and the patient left the hospital about several weeks later.

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

OBJECTIVES

The aim of this study was to examine the temporal trends and outcomes of mechanical complications after myocardial infarction in the contemporary era.

BACKGROUND

Data regarding temporal trends and outcomes of mechanical complications after ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) are limited in the contemporary era.

METHODS

The National Inpatient Sample database (2003 to September 2015) was queried to identify all STEMI and NSTEMI hospitalizations. Temporal trends and outcomes of mechanical complications after STEMI and NSTEMI, including papillary muscle rupture, ventricular septal defect, and free wall rupture, were described.

RESULTS

The analysis included 3,951,861 STEMI and 5,114,270 NSTEMI hospitalizations. Mechanical complications occurred in 10,726 of STEMI hospitalizations (0.27%) and 3,041 of NSTEMI hospitalizations (0.06%), with no changes in trends (p = 0.13 and p = 0.83, respectively). The rates of in-hospital mortality in patients with mechanical complications were 42.4% after STEMI and 18.0% after NSTEMI, with no significant trend changes (p = 0.62 and p = 0.12, respectively). After multivariate adjustment, patients who had mechanical complications after myocardial infarction had higher in-hospital mortality, cardiogenic shock, acute kidney injury, hemodialysis, and respiratory complications compared with those without mechanical complications. Predictors of lower mortality in patients with mechanical complications who developed cardiogenic shock included surgical repair in the STEMI and NSTEMI cohorts and percutaneous coronary intervention in the STEMI cohort.

CONCLUSIONS

Contemporary data from a large national database show that the rates of mechanical complications are low in patients presenting with STEMI and NSTEMI. Post-myocardial infarction mechanical complications continue to be associated with high mortality rates, which did not improve during the study period.

Prognostic relevance of pericardial effusion in STEMI patients treated by primary percutaneous coronary intervention: a 10-year single-centre experience

BACKGROUND

Pericardial effusion is frequent in the acute phase of ST-segment elevation myocardial infarction. However, its prognostic role in the era of primary percutaneous coronary intervention is not completely understood.

METHODS

We investigated the association between pericardial effusion, assessed by transthoracic echocardiography, and survival in a large cohort of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention, enrolled in the Trieste primary percutaneous coronary intervention registry from January 2007 to March 2017. Multivariable analysis and a propensity score approach were performed.

RESULTS

A total of 1732 ST-segment elevation myocardial infarction patients were included. Median follow-up was 45 (interquartile range 19-79) months. Pericardial effusion was present in 246 patients (14.2%). Thirty-day all-cause mortality was similar between patients with and without pericardial effusion (7.8% vs. 5.4%, P=0.15), whereas crude long-term survival was worse in patients with pericardial effusion (26.2% vs. 17.7%, P≤0.01). However, at multivariable analyses the presence of pericardial effusion was not associated with long-term mortality (hazard ratio 1.26, 95% confidence interval 0.86-1.82, P=0.22). Matching based on propensity scores confirmed the lack of association between pericardial effusion and both 30-day (hazard ratio 1, 95% confidence interval 0.42-2.36, P=1) and long-term (hazard ratio 1.14, 95% confidence interval 0.74-1.78, P=0.53) all-cause mortality. Patients with pericardial effusion experienced a higher incidence of free wall rupture (2.8% vs. 0.5%, P<0.0001) independently of the entity of pericardial effusion.

CONCLUSIONS

In acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, the onset of pericardial effusion after ST-segment elevation myocardial infarction is not independently associated with short and long-term higher mortality. Free wall rupture has to be considered rare compared to the fibrinolytic era and occurs more frequently in patients with pericardial effusion, suggesting a close monitoring of these patients in the early post-primary percutaneous coronary intervention phase.

Left Ventricular Free Wall Rupture in Transmural Myocardial Infarction

Left ventricular free wall rupture (LVFWR) is a grave complication of acute myocardial infarction (MI). We report a case of a 73-year-old male who developed LVFWR five days after a transmural MI. The diagnosis was confirmed with echocardiography, which showed a large pericardial effusion with a clot in the pericardial sac. This case emphasizes that a high index of clinical suspicion for the acute mechanical complications of MI should be present when managing patients with transmural MIs. In addition, stat echocardiography is necessary to diagnose LVFWR and initiate treatment.

Management of Left Ventricular Free Wall Rupture Associated with Acute Myocardial Infarction

Left ventricular free wall rupture is one of the mechanical complications of acute myocardial infarction and it may result in cardiac tamponade as well as limiting itself by forming a pseudoaneurysm. In this report, a case of left ventricular free wall rupture and pseudoaneurysm that developed during the course of posterior myocardial infarction has been presented. Left ventricular free wall rupture and pseudoaneurysm were identified by three-dimensional transthoracic echocardiography and surgically repaired at a late stage.