Cardiac rupture after ST elevation myocardial infarction – a decade's experience of a tertiary cardiology centre

 

Mechanical complications post ST elevation myocardial infarction (STEMI) are life-threating events, that require rapid recognition and appropriate management. Clinical diagnosis, considering high index of suspicion and bedside echocardiography should be considered in all STEMI patients

Despite the overall decrease of the incidence of cardiac rupture (CR) secondary to STEMI in context of early revascularization and the wide availability of primary PCI, CR has still an unacceptable high mortality.

Purpose

To provide demographic, clinical, management and prognostic data associated to cardiac rupture from a tertiary centre of cardiology in Romania and to better describe in-hospital trajectory.

The primary endpoint was defined as the incidence of CR and secondary endpoints were rate of surgical interventions, in-hospital mortality rate at 24 hours and after 24 hours during index hospitalization.

Methods

The analysis of the electronic medical records retrospectively identified 7703 patients admitted for STEMI between 01 Jan 2011 and 31 Dec 2020.

A database consisting of demographic data, medical history, cv and non-cv comorbidities, in-hospital management were recorded using an UiPath robotic process automation (RPA) technology. Characteristics of the patients +/− CR were compared, and data analysis was performed using SPSS 26 Ed.

Results

Of a total number of 7703 consecutive STEMI patients, CR has been identified in 185 patients (mean incidence of 2.4%). The annual rates for CR incidence remained stable during the past decade (Figure 1). Patients with CR were older compared with non-CR (71.6±10.2 vs 61.47±12.8 years; p<0.001) and more commonly female (3.92% vs 1.78% males, p=0.04).

The CR patients had more comorbidities and CV risk factors – HTN, smoker status, DLP, more AF, CKD, obesity and chronic cognitive deficit (p<0.05), but not DM (p=0.6).

Among the CR group patients, anterior MI was the frequent localisation (52%), followed by inferior MI (17%), infero-lateral (23%) and RV involvement MI (6.4%). According to the type of the mechanical complication, patients developed free wall rupture (50% of cases), 39% IVS rupture and 11% papillary muscle was involved; A number of 50 patients (27%), benefited from emergent cardiac surgery and 31.3% of CR patients received mechanical circulatory support. The overall STEMI mortality in the first 24-hours was 1.84% and in most of these patients the main cause of death was related to CR (31%). Overall total in-hospital mortality was 8.08% (6.5% non-CR group vs. 70.8% the CR group – Figure 1).

Conclusions

The study presents the epidemiological characteristics of CR complicating STEMI in the largest tertiary cardiovascular hospital in Romania. We have identified a stable trend for the incidence of CR incidence among patients with STEMI. In spite of the high rate of cardiac surgery and MCS, in-hospital mortality remains very high, particularly in the first 24 h since admission

Funding Acknowledgement

Type of funding sources: None.

[Usefulness of diastolic deceleration time assessed by transthoracic Doppler measurement in the detection of sustained microvascular obstruction in STEMI patients treated by primary PTCA]

AIMS

To assess the value of coronary flow measurement by transthoracic Doppler technique in the detection of "no-reflow" phenomenon.

METHODS

Fourteen patients with first anterior wall infarction treated by successful (TIMI3) primary percutaneous angioplasty and left descending coronary artery stenting were investigated. Myocardial perfusion following PCI was assessed by (i) ST-segment resolution, (ii) MRI-detected microvascular obstruction (early hypoenhancement), (iii) coronary flow pattern measurement by transthoracic Doppler technique.

RESULTS

Sustained impairment of myocardial perfusion following PCI was observed in a large proportion of the cohort (36% by MRI, 43% by ST regression analysis). Patients with a diastolic deceleration time inferior to 482 ms had higher troponin and CK peak value, higher wall motion index score, lower ST resolution and lower LVEF assessed by MRI. The concordance of the three methods was 80%.

CONCLUSION

The measurement of diastolic deceleration time by transthoracic Doppler technique is a reliable technique to identify microvascular obstruction following PCI in acute anterior STEMI. A DDT inferior to 482 ms is associated with sustained "no-reflow" phenomenon.

[Myonecrosis and inflammatory response following percutaneous coronary angioplasty. A protective role for betablockers?]

INTRODUCTION

Percutaneous coronary intervention (PCI) is widely used actually for the treatment of coronary disease. Stent implantation in the vessel wall is associated with local healing processes and some myonecrosis. However, little is known about the relationships between systemic inflammatory response, myonecrosis and the patient's and procedural characteristics.

OBJECTIVES

(i) To evaluate the level of C-Reactive Protein (hsCRP) and cardiac troponin I (cTnI) elevation after PCI; (ii) to determine the patient's and procedural factors associated with those elevations.

METHOD

This is a prospective monocentric study carried out in patients hospitalised for elective PCI or for ACS without cTnI elevation. CRP and cTnI were assessed before, after and 24 hours after the procedure.

RESULTS

Thirty-four patients (mean age 64+/-10.9 years; sex ratio 28 males/six females) were included. hsCRP increased in 26 patients (76.4%) and cTnI in 16 patients (47%) after PCI. cTnI elevation did not correlate with inflammatory response. Whereas none of the studied parameters were statistically linked with hsCRP increase, cTnI elevation was significantly associated with AHA-ACC B(2)/C type lesion, the number and the total length of stents implanted, the duration of procedure and treatment by betablockers. Multivariate analysis showed that the independent predictors of cTnI elevation were procedure duration (p=0.032 OR=14.2 CI 95% 7.69-100) and the absence of pretreatment with betablockers (p=0.036, OR=2,6 CI 95% 1.35-35).

CONCLUSION

cTnI elevation following PCI is very frequent and related with the duration of the procedure. Our data suggest a protective role of betablockers in the occurrence of cTnI elevation after PCI. Confirmation of the protective role of betablockers in larger cohort is mandatory.

[Mycobacterium marinum. A rare cause of infection of the skin and joints]

Mycobacterium marinum is a rare cause of disseminated infection in man. The case report describes an 80-year-old woman, who had been treated with oral corticosteroids for bronchial asthma for 40 years, and in the same period had been swimming daily in swimming pools. At the first admission, the symptoms and clinical findings were interpreted as seronegative rheumatoid arthritis. After eight years of disease with recurrent infections of the skin, periarticular tissues and joints in the hands and one elbow, a biopsy specimen from an abscess showed granulomatous inflammation and acid fast bacilli. Culture for mycobacteria grew M. marinum. There was a severe, destructive monoarthritis in the right second metacarpophalangeal joint. The patient recovered completely on treatment with clarithromycin and doxycycline.