Mechanical complications in STEMI: prevalence and mortality trends in the primary PCI era. The Ruti-STEMI registry

INTRODUCTION AND OBJECTIVES

Mechanical complications confer a dreadful prognosis in ST-elevation myocardial infarction (STEMI). Their prevalence and prognosis are not well-defined in the current era of primary percutaneous coronary intervention (pPCI) reperfusion networks. We aimed to analyze prevalence and mortality trends of post-STEMI mechanical complications over 2 decades, before and after the establishment of pPCI networks.

METHODS

Prospective, consecutive registry of STEMI patients within a region of 850 000 inhabitants over 2 decades: a pre-pPCI period (1990-2000) and a pPCI period (2007-2017). We analyzed the prevalence of mechanical complications, including ventricular septal rupture, papillary muscle rupture, and free wall rupture (FWR). Twenty eight-day and 1-year mortality trends were compared between the 2 studied decades.

RESULTS

A total of 6033 STEMI patients were included (pre-pPCI period, n=2250; pPCI period, n=3783). Reperfusion was supported by thrombolysis in the pre-pPCI period (99.1%) and by pPCI in in the pPCI period (95.7%). Mechanical complications developed in 135 patients (2.2%): ventricular septal rupture in 38 patients, papillary muscle rupture in 24, and FWR in 73 patients. FWR showed a relative reduction of 60% in the pPCI period (0.8% vs 2.0%, P<.001), without significant interperiod changes in the other mechanical complications. After multivariate adjustment, FWR remained higher in the pre-pPCI period (OR, 1.93; 95%CI, 1.10-3.41; P=.023). At 28 days and 1 year, mortality showed no significant changes in all the mechanical complications studied.

CONCLUSIONS

The establishment of regional pPCI networks has modified the landscape of mechanical complications in STEMI. FWR is less frequent in the pPCI era, likely due to reduced transmural infarcts.

Myocardial rupture and systemic lupus erythematosus: a case report

Background

Systemic erythematous lupus (SLE) is an autoimmune disease associated with significant cardiovascular morbidity and mortality, even in young patients.

Case summary

A young female with recently diagnosed SLE under corticotherapy developed pulmonary oedema and respiratory failure. The diagnostic workup revealed mildly elevated cardiac troponin, significantly elevated NT-proB-type natriuretic peptide (NT-proBNP) and mild pericardial effusion without other echocardiographic abnormalities. Systemic erythematous lupus-associated myocarditis was presumed, and her clinical status improved after corticotherapy intensification. However, transthoracic echocardiogram repeated days later revealed a large pericardial effusion with findings suggestive of a contained myocardial rupture originating in the inferolateral basal left ventricular (LV) segment, which was confirmed by computed tomography scan. Cardiac catheterization exhibited normal coronary arteries. The patient was submitted to cardiac surgery and the LV pseudoaneurysm was successfully repaired.

Discussion

Myocardial rupture with LV pseudoaneurysm formation usually occurs in the setting of acute myocardial infarction, but also in other rare contexts. Cardiac rupture is associated with an extremely high mortality unless early diagnosis and urgent surgical intervention are provided.

Blood group A: a risk factor for heart rupture after acute myocardial infarction

Introduction

Studies have been performed to identify the association between ABO blood groups and coronary artery disease. However, data is scarce about the impact of ABO blood groups on heart rupture (HR) after acute myocardial infarction (AMI).

Methods

We conducted a retrospective case–control study that included 61 consecutive patients with HR after AMI during a period from 1 January 2012 to 1 December 2019. The controls included 600 patients who were selected randomly from 8143 AMI patients without HR in a ratio of 1:10. Univariate and multivariate logistic regression analysis were used to identify the association between ABO blood groups and HR.

Results

Patients with blood group A had a greater risk of HR after AMI than those with non-A blood groups (12.35% vs 7.42%, P < 0.001). After adjusting for age, gender, heart rate at admission, body mass index (BMI), and systolic blood pressure (SBP), blood group A was independently related to the increased risk of HR after AMI (OR = 2.781, 95% CI 1.174–7.198, P = 0.035), and remained as an independent risk factor of HR after AMI in different multivariate regression models.

Conclusion

Blood group A is significantly associated with increased HR risk after AMI.

Primary effusion lymphoma in a human immunodeficiency virus-negative patient with unexpected unusual complications: a case report

BACKGROUND

Primary effusion lymphoma is a rare, high-grade non-Hodgkin's lymphoma that usually occurs in immunosuppressed or human immunodeficiency virus-positive individuals in advanced stages of the disease. However, primary effusion lymphoma occasionally affects immunocompetent patients who are infected with human herpes virus type 8 or Epstein-Barr virus. This disease manifests with liquid collections in cavities, producing constitutional symptoms; fever; weight loss; and symptoms related to extrinsic compression, such as dyspnea or abdominal discomfort. Diagnosis is confirmed with cytological or tissue evaluation showing large, multinucleated lymphoid cells with positive specific markers for the disease, such as CD45 and markers related to viral infections, when present. There is no standard treatment for primary effusion lymphoma, but several chemotherapy protocols are recommended, usually with poor results.

CASE PRESENTATION

We present a case of an adult human immunodeficiency virus-negative Hispanic origin woman with primary effusion lymphoma with pleuritic, pericardial, and peritoneal compromise who also had unusual complications during a diagnostic procedure: the accidental rupture of the left ventricle and the development of a secondary left ventricular pseudoaneurysm. We describe the clinical, radiological, and laboratory characteristics as well as the outcome of this case.

CONCLUSIONS

Primary effusion lymphoma is a very rare entity that represents 4% of non-Hodgkin's lymphoma cases associated with human immunodeficiency virus and 0.1% to 1% of all lymphomas in patients with another type of immunodeficiency in regions where human herpes virus type 8 is not endemic. This reported case is an unusual presentation of primary effusion lymphoma because it occurred in an immunocompetent human immunodeficiency virus-negative adult woman without the presence of Kaposi's sarcoma or Castleman's disease and for whom the clinical course after chemotherapy was successful. However, the rupture of the free wall of the left ventricle is a very rare catastrophic event that usually occurs after myocardial infarction. Left ventricle free wall rupture rarely goes unnoticed, but when it occurs, it leads to the development of a ventricular pseudoaneurysm in which the rupture is contained by the pericardium with an organized thrombus and an adjacent hematoma.

[Treatment experience of cardiac rupture in patients with acute myocardial infarction]

Objective: To analyze the treatment results of cardiac rupture in patients with acute myocardial infarction (AMI) . Method: Clinical data of 6 with cardiac rupture after AMI, who were hospitalized in our hospital from June 2015 to June 2017, were retrospectively analyzed,and the clinical manifestations, methods of treatment and outcomes were investigated. Results: Cardiac function classification was Killip class Ⅱin all patients. There were 3 massive anterior wall myocardial infarction, 2 anterior wall myocardial infarction,and 1 inferior myocardial infarction. There were 4 patients with ventricular septal defect, 1 patient with rupture of papillary muscle,and 1 patient with left ventricular free wall rupture.All patients received continuous infusion of vasoactive medicines and treated with intra-aortic balloon pump(IABP), 2 patients (1 patient accepted operative treatment,and 1 patient received conservative treatment) were treated with extracorporeal membrane oxygenation (ECMO), mechanical ventilation,and continuous renal replacement therapy(CRRT).Three patients received surgical repair,1 case was supported by IABP, 1 case supported by ECMO,CRRT,and IABP,and 1 case did not use IABP or ECMO post operation. All 3 surgically treated patients recovered successfully and were discharged from hospital.Meanwhile, in the other 3 patients treated conservatively, 2 patients died in the hospital and 1 patient was discharged according to own will. Conclusion: On the basis of vasoactive medicines and IABP, surgery repair is a feasible option for cardiac rupture patients secondary to AMI,and ECMO may improve the perioperative state in these patients.

Left ventricle pseudoaneurysm: Diagnosis by a new murmur

Incomplete rupture of the ventricle free wall can occur after myocardial infarction. This occurs when an organized thrombus and the pericardium seal the ventricular perforation. This can progress to the formation of a left ventricle pseudoaneurysm (LVPA). A 70-year-old male with an antero-septal ST-elevation myocardial infarction (STEMI) underwent an emergent left heart catheterization which revealed severe three-vessel disease with occluded grafts, non-amenable to re-vascularization, and an apical thrombus. As he was high-risk for repeat coronary artery bypass graft, he was medically managed. Transthoracic echocardiogram (TTE) showed a normal left ventricle ejection fraction (LVEF), apical anterior and inferior wall akinesis, moderate sized apical thrombus, and pericardial thickening. On hospital day 7, examination revealed a new 3/6 to-and-fro murmur that was loudest at the apex. The patient was asymptomatic with normal vital signs. A repeat TTE revealed an apical wall rupture with flow into the pericardial cavity and absence of the apical thrombus. A LVPA was diagnosed and the patient was immediately referred for surgical repair. This case illustrates the potential for developing LVPA in STEMI patients and the importance of physical examination. If identified early a potential emergent situation in a previously asymptomatic patient can be averted, thereby preventing fatal consequences. <Learning objective: With the growing use of diagnostic testing the importance of physical examination is being lost. However, with an astute cardiac examination, potential complications such as a left ventricular pseudoaneurysm can be identified and promptly managed. In addition, a ventricular pseudoaneurysm must be considered in the differential as a rare complication in post ST-elevation myocardial infarction patients with a new murmur.>.

Postinfarction ventricular septal rupture closure without ventriculotomy

Postinfarction ventricular septal rupture is a life-threatening complication of acute myocardial infarction. Although some novel techniques of ventricular septal rupture closure have been introduced, they involve ventriculotomy, a procedure that can cause a degree of impairment of the incised ventricle. We describe a case in which we closed a ventricular septal rupture through the tricuspid valve, without ventriculotomy.

[Gastric Mucormycosis Followed by Traumatic Cardiac Rupture in an Immunocompetent Patient]

Gastric mucormycosis is a rare and life-threatening fungal disease, caused by fungus in the order Mucorales. While rhino-cerebral and pulmonary forms are common, gastric mucormycosis is an uncommon site for the disease. We diagnosed gastric mucormycosis in a 41-year-old female who had severe multiple trauma, including cardiac rupture, due to a traffic accident. Eighteen days after hospitalization, she passed 800 mL of melena over one day. We performed upper esophagogastroduodenoscopy (EGD) and found a huge gastric ulcer with bleeding. Histopathological examination identified non-septated and right-angled branching fungal hyphae, and we diagnosed gastric mucormycosis. We recommended total gastrectomy to her but she refused the operation, so she was treated with liposomal amphotericin B for 53 days. After two months of treatment with liposomal amphotericin B, we again performed EGD and found a healed gastric ulcer. After four months, with another EGD, we found that the gastric mucormycosis was completely healed.

Severe Tricuspid Regurgitation Diagnosed 13 Years after a Car Accident: A Case Report

Blunt chest traumas mostly occur due to car accidents and can cause many cardiac complications such as septal rupture, free-wall rupture, coronary artery dissection or thrombosis, heart failure, arrhythmias, and chordae and papillary muscle rupture. One of the most serious complication is tricuspid regurgitation (TR), which can be simply diagnosed by physical examination and confirmed by echocardiography. We describe a 48-year-old female patient, diagnosed with severe TR 13 years after a blunt chest trauma due to a car accident. TR was diagnosed with transthoracic echocardiography and three dimensional transthoracic echocardiography had defined the exact pathology of the tricuspid valve. The patient underwent successful surgery with bioprosthetic valve implantation and was discharged at 6th postoperative day without any complication. The patient had no problem according to the follow-up one month and six months after operation.

Trends in the clinical and pathological characteristics of cardiac rupture in patients with acute myocardial infarction over 35 years

Background

There is little known about whether the clinical and pathological characteristics and incidence of cardiac rupture (CR) in patients with acute myocardial infarction (AMI) have changed over the years.

Methods and Results

The incidence and clinical characteristics of CR were investigated in patients with AMI, who were divided into 3 cohorts: 1977–1989, 1990–2000, and 2001–2011. Of a total of 5699 patients, 144 were diagnosed with CR and 45 survived. Over the years, the incidence of CR decreased (1977–1989, 3.3%; 1990–2000, 2.8%; 2001–2011, 1.7%; P=0.002) in association with the widespread adoption of reperfusion therapy. The mortality rate of CR decreased (1977–1989, 90%; 1990–2000, 56%; 2001–2011, 50%; P=0.002) in association with an increase in the rate of emergent surgery. In multivariable analysis, first myocardial infarction, anterior infarct, female sex, hypertension, and age >70 years were significant risk factors for CR, whereas impact of hypertension on CR was weaker from 2001 to 2011. Primary percutaneous coronary intervention (PPCI) was a significant protective factor against CR. In 64 autopsy cases with CR, myocardial hemorrhage occurred more frequently in those who underwent PPCI or fibrinolysis than those who did not receive reperfusion therapy (no reperfusion therapy, 18.0%; fibrinolysis, 71.4%; PPCI, 83.3%; P=0.001).

Conclusions

With the development of medical treatment, the incidence and mortality rate of CR have decreased. However, first myocardial infarction, anterior infarct, female sex, and old age remain important risk factors for CR. Adjunctive cardioprotection against reperfusion‐induced myocardial hemorrhage is emerging in the current PPCI era.

Blunt traumatic left atrial appendage rupture and cardiac herniation

A 42-year-old man sustained blunt thoracic trauma after a motor vehicle accident. He underwent an urgent operation. Operative findings included a large hematoma, a 4-cm tear in the left atrial appendage, and a long pleuropericardial rupture along the right phrenic nerve. We repaired the left atrial appendage without cardiopulmonary bypass, and closed the pericardial defect primarily. The patient recovered fully and was discharged on the 6th postoperative day.

Biological glue application in repair of atrioventricular groove rupture: a case report

Atrioventricular groove rupture is a rare, albeit mortal, complication following mitral valve surgery. Avoidance is the best strategy but it cannot fully prevent the occurrence of this complication. Several repair techniques have been described with varying success rates; however, the rarity of the complication precludes consensus about the safest technique. Here we report two cases of posterior atrioventricular groove rupture. Both cases were diagnosed immediately after the cessation of cardiopulmonary bypass. Repair was performed successfully with a technique involving the use of biological glue. The postoperative course was uneventful for both of them. Both cases are well with normally functioning mitral prostheses; one with a follow-up time of 5.5 years and the other 10 months. We believe that the glue provides additional hemostasis and support to the repaired area.

Surgical treatment of post-infarction left ventricular free wall rupture: three cases review

Left ventricular free wall rupture (LFWR) is rare, but is one of the most serious complications of myocardial infarction and is associated with high mortality. Several operative techniques have been attempted, but early diagnosis and prompt surgical management are crucial for a positive patient outcome. We report three cases of LFWR successfully treated with surgical methods.

Timely diagnosis of left ventricular posterior wall rupture by echocardiography: a case report

Left ventricular free wall rupture is responsible for up to 10% of in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction, and its antemortem diagnosis is rarely made.One of the medical complications of myocardial infarction is the rupture of the free wall, which occurs more frequently in the anterolateral wall in hypertensives, women, and those with relatively large transmural myocardial infarction usually 1-4 days after myocardial infarction.We herein present the case of a 66-year-old man suffering inferior wall myocardial infarction with abrupt hemodynamic decompensation 9 days after myocardial infarction. Emergent transthoracic echocardiography revealed massive pericardial effusion with tamponade, containing a large elongated mass measuring 1 × 8cm suggestive of hematoma secondary to cardiac rupture. In urgent cardiac surgery, the posterior wall between the left coronary artery branches was ruptured.