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Surgical and transcatheter treatments of mechanical complications of acute myocardial infarction
  1. James M McCabe1,
  2. Christine J Chung2
  1. 1 Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
  2. 2 Medicine, University of Washington School of Medicine, Seattle, Washington, USA
  1. Correspondence to Dr James M McCabe, University of Washington School of Medicine, Seattle, WA 98195, USA; jmmccabe{at}uw.edu

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Learning objectives

  • To review the epidemiology, clinical presentation and diagnosis of mechanical complications of acute myocardial infarction including ventricular septal defect, free wall rupture and papillary muscle rupture.

  • To discuss the existing data on outcomes of medical therapy, surgery and percutaneous intervention.

  • To examine the limitations of currently available treatment modalities and need, as well as opportunity, for ongoing evolution and improvement of surgical and percutaneous therapies.

  • To highlight the importance of the heart team in facilitating complex, shared decision making in treating these conditions which carry very high morbidity and mortality.

Introduction

Major advances in reperfusion therapies after acute myocardial infarction (AMI) have resulted in dramatic reductions in the rate of mechanical complications including ventricular septal defect (VSD), free wall rupture (FWR) and papillary muscle rupture (PMR). However, the drastic decline in their incidence has not been accompanied by a similar decrease in their risk of major morbidity and mortality, which have remained mostly unchanged for the past two decades in the contemporary era of primary percutaneous coronary intervention (PCI). A multidisciplinary heart team approach facilitates timely recognition, diagnosis and management of complex haemodynamics and shared decision making regarding pursuit of a definitive intervention or palliation. There are few high-quality studies to guide management of these complex patients, leading to significant variability in care patterns that depend on local expertise and resource availability. The purpose of this review is to describe the clinical presentation of these patients, summarise the existing evidence to guide management, and highlight outcomes with a focus on evolving surgical and percutaneous treatment options.

Ventricular septal defect

Presentation and diagnosis

In the prethrombolytic era, VSD was estimated to occur in 1%–2% of AMI cases, typically occurring in the first week after infarction. In the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial, VSD was seen in 84 of 41 021 …

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Footnotes

  • Twitter @jamiemccabeMD, @CJChungMD

  • Contributors CJC participated in the conception, writing and editing of this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CC is a consultant for Boston Scientific, Edwards Lifesciences and Medtronic. JM is a consultant for Boston Scientific, Edwards Lifesciences and Medtronic and has equity in Excision Medical and ConKay Medical.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note References which include a * are considered to be key references.