Top Things to Know: Mechanical Complications of Acute Myocardial Infarction
Published: June 15, 2021
- In papillary muscle rupture (PMR), emergency mitral valve replacement (MVR) is the treatment of choice, but for patients with partial PMR and stable hemodynamics, MV repair may be an option for surgeons with the appropriate technical expertise.
- In select patients with PMR and prohibitive surgical risk, transcatheter edge-to-edge MV repair can be an effective treatment as part of a multidisciplinary “Heart Team” approach to management.
- While MV surgery is the standard of care for PMR, in patients with contraindications to surgery, treatment options include medical management as a bridge to candidacy for MVR, transcatheter edge-to-edge repair, and temporary mechanical support as a bridge to long term ventricular assist device or heart transplantation.
- Post-infarction ventricular septal defect (VSD) caused by rupture of infarcted myocardium typically occurs 3 to 5 days after a transmural AMI in <0.3% of patients in the contemporary era of routine primary revascularization. Immediate afterload reduction is the mainstay of initial therapy; periprocedural temporary mechanical support can also be used as an adjunct to decompress the left ventricle and support cardiac output.
- Determining optimal timing of surgical treatment of VSD is a shared decision between the cardiac surgeon, cardiologist and cardiac intensivist, and the severity of cardiogenic shock, organ failure and risk of coagulopathy due to antiplatelet medication should be factored in the decision making. Options in patients who are not candidates for VSD repair include percutaneous closure, mechanical support to heart transplantation, and palliative medical therapy.
- In VSD, high clinical suspicion, prompt diagnosis confirmed by echocardiography, and immediate surgery are needed; extracorporeal membrane oxygenation (ECMO) may be used for pre-operative stabilization.
- While surgical technique for management of free wall rupture continues to evolve, a primary patch repair that covers the defect, and when feasible a sutureless repair utilizing a patch and glue or a collagen sponge patch, can be used in a small subset of patients as an adjunct therapeutic option.
- Pseudoaneurysm with small necks can be repaired with pledgeted sutures buttressed by polytetrafluoroethylene felt, but Gore-Tex, pericardium, or a double patch Dacron can also be utilized to repair the defect with good surgical outcomes.
- Percutaneous repair of pseudoaneurysm can be done using a multidisciplinary “Heart Team” approach in centers with structural heart disease expertise.
- Multidisciplinary teams comprised of cardiac intensivists, non-invasive cardiologists, heart failure/transplant specialists, interventional cardiologists, cardiac surgeons, palliative care specialists, nursing, and allied healthcare professionals have the potential to improve adherence to best practice recommendations, decrease adverse events, and increase patient survival. In addition, patients and family members should be actively engaged in treatment decision-making within the cardiac intensive care unit (CICU).
Citation
Damluji AA, van Diepen S, Katz JN, Menon V, Tamis-Holland JE, Bakitas M, Cohen MG, Balsam LB, Chikwe J; on behalf of the American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Surgery and Anesthesia; and Council on Cardiovascular and Stroke Nursing. Mechanical complications of acute myocardial infarction: a scientific statement from the American Heart Association [published online ahead of print June 15, 2021]. Circulation. doi: 10.1161/CIR.0000000000000985.