Ventricular Free Wall Rupture Research Articles

Cardiac Myocyte-Specific Overexpression of FASTKD1 Prevents Ventricular Rupture After Myocardial Infarction.

Background The mitochondrial mRNA-binding protein FASTKD1 (Fas-activatedserine/threonine[FAST] kinase domain-containing protein 1) protects myocytes from oxidative stress in vitro. However, the role of FASTKD1 in the myocardium in vivo is unknown. Therefore, we developed cardiac-specific FASTKD1 transgenic mice to test the effects of this protein on experimental myocardial infarction (MI). Methods and Results Transgenic mouse lines with cardiac myocyte-specific overexpression of FASTKD1 to varying degrees were generated. These mice displayed normal cardiac morphological features and function at the gross and microscopic levels. Isolated cardiac mitochondria from all transgenic mouse lines showed normal mitochondrial function, ATP levels, and permeability transition pore activity. Male nontransgenic and transgenic mice from the highest-expressing line were subjected to 8 weeks of permanent coronary ligation. Of nontransgenic mice, 40% underwent left ventricular free wall rupture within 7 days of MI compared with 0% of FASTKD1-overexpressing mice. At 3 days after MI, FASTKD1 overexpression did not alter infarct size. However, increased FASTKD1 resulted in decreased neutrophil and increased macrophage infiltration, elevated levels of the extracellular matrix component periostin, and enhanced antioxidant capacity compared with control mice. In contrast, markers of mitochondrial fusion/fission and apoptosis remained unaltered. Instead, transcriptomic analyses indicated activation of the integrated stress response in the FASTKD1 transgenic hearts. Conclusions Cardiac-specific overexpression of FASTKD1 results in viable mice displaying normal cardiac morphological features and function. However, these mice are resistant to MI-induced cardiac rupture and display altered inflammatory, extracellular matrix, and antioxidant responses following MI. Moreover, these protective effects were associated with enhanced activation of the integrated stress response.

A Case of Post-Myocardial Infarction Ventricular Septal Rupture and Intramyocardial Dissection

Ventricular septal rupture (VSR), albeit rare, is a deadly consequence of ST elevation myocardial infarction (STEMI). Our patient described here presented with both post-infarction VSR and intramyocardial dissection (IMD) of the right ventricle (RV), a subtype of left ventricular free wall rupture (LVFWR). This case highlights the importance of prompt diagnosis of these post-myocardial infarction (MI) complications and the current limitations of surgical and percutaneous repair.

Left Ventricular Free Wall Rupture Immediately following Successful Coronary Reperfusion Complicating ST Elevation Myocardial Infarction.

Left Ventricular Free Wall Rupture Immediately following Successful Coronary Reperfusion Complicating ST Elevation Myocardial Infarction.

Left Ventricular Free Wall Rupture Complicated by Post-Transfusion Purpura: A therapeutic challenge

Left Ventricular Free Wall Rupture Complicated by Post-Transfusion Purpura: A therapeutic challenge

Abstract 12968: Survival of a Left Ventricular Free Wall Rupture in a 52-Year-Old Female

Introduction: Ventricular free wall rupture is an often fatal STEMI complication that has become increasingly rare thanks to early treatment of STEMI with primary percutaneous coronary intervention. Mortality is extremely high, with survival being dependent on early diagnosis and intervention as demonstrated in our case. Case: A 52 year old female with multi-vessel CAD and current tobacco use presented for acute, severe chest pain radiating to the jaw, throat, and upper back. She had been discharged the day prior after being medically managed for an inferior STEMI that had poor distal targets for CABG. Chest pain had been improving at time of discharge, but acutely worsened again the day of presentation and was accompanied by dyspnea. BP was persistently hypotensive despite aggressive fluid resuscitation. Physical exam was notable for diffuse tenderness of chest wall. Patient was alert and oriented. Troponin was down-trending from initial inferior infarct but still elevated. EKG still showed inferior infarct with no new changes. CTA chest, abdomen, and pelvis demonstrated hemopericardium and a linear focus of contrast enhancement involving the inferior left ventricular wall was seen on post-contrast images as shown in Figure 1. Patient was emergently taken to OR where intraoperative TEE with color doppler demonstrated color flow across the mid inferolateral wall consistent with myocardial perforation as seen in Figure 2. The hemopericardium was evacuated, a single-vessel coronary artery bypass-SVG to RPL was performed, and the myocardial rupture was closed with a pericardial patch. Patient survived and remained in the ICU for 10 days before being discharged.

Abstract 10604: Critical Role of Cardiac Imaging of Mechanical Complication in ST Elevation Myocardial Infarction: Left Ventricular Free Wall Rupture Diagnosed With CTA and Echocardiography

Case Presentation: An 81-year-old male with a thymoma (treated with surgery including partial pericardiectomy 25 years prior) presented to his local ER with chest pain radiating to his back. Vital signs were stable. EKG showed ST elevations in the lateral leads with Q waves. Troponin was positive. Diagnosis included STEMI as well as possible aortic dissection. CT angiography (CTA) did not show dissection; however, contrast extravasation and left ventricular (LV) free wall rupture was noted. Patient was not given thrombolysis and transferred for tertiary care. On arrival, the patient was pain free, hemodynamically stable, and an echo was obtained. Color Doppler and echo contrast confirmed a LV outpouching along the lateral wall with a “narrow neck” consistent with a pseudoaneurysm (PsA, figure 1). CT surgery declined an emergent operation due to the high risk of mortality with early operative intervention and recommended initial conservative management. After 48 hours, a repeat CTA showed increased size of the PsA (figure 2). The patient chose to be managed medically and eventually passed away 8 days after presentation. Discussion: This patient had a contained LV rupture as a STEMI complication. The CTA showed LV rupture and thrombolysis was avoided. Echo confirmed the diagnosis. This case highlights 1) the utility of imaging in in the diagnosis of LV rupture as it is usually limited by early mortality, and 2) its role in differentiating PsA from true aneurysm, which is characterized by a contained wall rupture while true aneurysms develop due to a weakened, but intact, wall.

The Moment of Left Ventricular Free-wall Rupture.

The Moment of Left Ventricular Free-wall Rupture.

Intra-pericardial thrombin injection as bailout strategy in iatrogenic pericardial tamponade.

Cardiac tamponade is arare but life-threatening complication of cardiac interventions. Despite prompt pericardiocentesis, clinical management can be challenging and sometimes haemodynamic stabilisation is difficult to achieve. Intra-pericardial thrombin injection after pericardiocentesis promotes haemostasis and acts as asealing agent, as previously described for left ventricular free-wall rupture. We aimed to evaluate intra-pericardial thrombin injection as abailout strategy for pericardial tamponade following percutaneous cardiac interventions. In a5-year single-centre retrospective analysis we identified 31patients with cardiac tamponade due to percutaneous intracardiac procedures. Intra-pericardial thrombin injection as abailout strategy was administered in 5of 31patients (16.1%). Patients receiving intra-pericardial thrombin were in amore critical state when thrombin was applied, as demonstrated by ahigher rate of resuscitation (40% versus 26.9%) and atrend toward aprolonged stay in the intensive care unit (177.6 ± 84.0 vs 98.0 ± 31.4 h). None of the patients with pericardial tamponades treated with intra-pericardial thrombin needed cardiothoracic surgery. Mortality after 30days was lower with intra-pericardial thrombin injection than with standard treatment (0% vs 15.4%). We observed no complications using intra-pericardial thrombin. Intra-pericardial thrombin injection could be considered as abailout strategy for patients with iatrogenic pericardial tamponade due to percutaneous procedures. We recommend further evaluation of this technique in the clinical management of refractory pericardial tamponade.

Left ventricular pseudoaneurysm: the niche of post-infarction mechanical complications.

Left ventricular pseudoaneurysm (LVP) is a very rare, but potentially lethal mechanical complication of acute myocardial infarction (AMI). Despite representing a unique subset of cardiac rupture, it presents peculiar features that distinguish it from both ventricular free-wall rupture (FWR) and ventricular true aneurysm. LVP occurs in less than 0.5% of patients affected by AMI. However, LVP is generally burdened by high mortality, often related to false cavity rupture, leading to catastrophic and often irreversible consequences. The risk of rupture is inversely proportional to the timing from AMI onset, which also determines both the classification of LVP and drives the indication for treatment. Despite the lack of a current consensus on LVP management, urgent surgery is the treatment of choice for LVPs occurring within 3 months from AMI, especially if larger than 3 cm in diameter. A matter of debate, however, is represented by chronic LVPs, especially because the risk of rupture decreases progressively as time passes and left ventricular (LV) false cavity stabilizes. Surgical mortality rate remains not negligible (more than 20%), but these suboptimal results may be considered acceptable, especially considering the lethality associated with the occurrence of pseudoaneurysm rupture. Diagnostic workup is essential for anatomical characterization of LV rupture, which is mandatory to guide the decision on surgical approach and technique for pseudoaneurysm repair. Finally, for a subset of patients with anterior LVP and a well-defined fibrotic neck, and deemed at excessively high surgical risk, percutaneous closure of the cavity has been described with encouraging results.

Surgical repair of post-infarction ventricular free-wall rupture in the Netherlands: data from a nationwide registry.

Ventricular free-wall rupture (VFWR) is an infrequent but catastrophic complication of acute myocardial infarction (AMI). Most reports about outcome after surgical treatment are single-center experiences. We examined the early and mid-term outcomes after surgical repair of post-AMI VFWR using the Netherlands Heart Registration (NHR) database. We included data from NHR patients (>18 years old) who underwent surgery for post-AMI VFWR between 2014 and 2019. The primary end-point was in-hospital mortality. Secondary outcomes included postoperative complications and mid-term survival. The study included 148 patients (54.7% male, mean age 66.5±11.1 years). Critical preoperative status was found in 62.6% of subjects. In-hospital mortality was 31.1% (46 of 148). Multivariable analysis identified female sex [odds ratio (OR), 5.49; 95% confidence interval (CI): 2.24-13.46] and critical preoperative status (OR, 4.06; 95% CI: 1.36-12.13) as independent predictors of in-hospital mortality. The overall median postoperative follow-up was 2.2 (interquartile range, 0.7-3.8) years. Overall survival rates at three and five years were 58.9% and 55.7%, respectively. Among hospital survivors, only 15 (14.7%) patients died during follow-up, with a five-year survival rate of 80.8%. In-hospital mortality after surgical repair of post-AMI VFWR is considerable. Female sex and preoperative critical status are independent predictors of early postoperative (in-hospital) death. Logistic EuroSCORE I can reliably predict in-hospital mortality (optimal cut-off >33%). Mid-term follow-up of patients surviving in-hospital course shows excellent results.

Left Ventricular Free-Wall Rupture After Late-Admission STEMI.

This case illustrates a rare but catastrophic complication of acute myocardial infarction, ie, acute rupture of the left ventricular free wall. The majority of patients have hemodynamic impairment on arrival, and a high level of suspicion is needed. Point-of-care echocardiogram is valuable for prompt diagnosis. Management is very challenging and is based on fluid infusion, inotropic support, and pericardiocentesis. Emergency coronary artery bypass grafting and ventricular wall suture may be the only definitive treatment available, although in the majority of cases timely treatment is not possible.

Systematic review and meta-analysis of the mechanical complications of ischemic heart disease: papillary muscle rupture, left ventricle rupture and post-infarct ventricular septal defect.

Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a purely percutaneous, transcatheter strategy. Through systematic review, this study aims to synthesise the collective experience of percutaneous treatment of the mechanical complications of ischaemic heart disease. The search strategy queried the electronic databases PubMed, Embase and the Cochrane Central Register of Controlled Trials, from 1 January 2000 to 31 December 2020. Studies highlighting the outcomes of patients receiving percutaneous treatment of post-myocardial infarction papillary muscle rupture (PMR), ventricular septal defect (VSD), left ventricular free wall rupture (FWR) and pseudoaneurysm (PA) were included. A qualitative review of studies was conducted for PMR, FWR and PA. A quantitative analysis was conducted for VSD. Fifteen studies were included in the qualitative synthesis of the percutaneous management of PMR, 4 were included in the qualitative analysis of the percutaneous management of left ventricular FWR, 7 studies defined the outcomes of the percutaneous management of PA and 25 were included in the quantitative meta-analysis of the primary percutaneous management of post-MI VSD. For VSD, there were 43 failed procedures in 314 patients. The proportion of failed procedures was 15.9% and there were 174 deaths in 428 patients. 37.5% of patients experienced early mortality. Although surgical techniques remain the gold standard, we have shown that percutaneous management may be a viable option in certain cases.

Sutureless repair techniques for post-infarction left ventricular free wall rupture.

Left ventricular free wall rupture after acute myocardial infarction is uncommon but lethal and is still associated with high mortality rates. This paper presents the surgical treatment options and clinical management for post-infarction left ventricular free wall rupture. Various types of techniques, specifically sutureless repair using TachoComb/TachoSil, and intraoperative video images are discussed. Currently, sutureless repair is the most recommended treatment option when possible. However, appropriate selection of the surgical procedure remains important.

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.

Effects of concomitant coronary artery bypass grafting on early and late mortality in the treatment of post-infarction mechanical complications: a systematic review and meta-analysis.

Mechanical complications of acute myocardial infarction represent life-threatening events, including ventricular septal rupture (VSR), left ventricular free-wall rupture (LVFWR) and papillary muscle rupture (PMR). In-hospital mortality is high, even when prompt surgery can be offered. The role of concomitant coronary artery bypass grafting (CABG) in the surgical treatment of these conditions is still debated. A systematic review of the literature, from 2000 onwards, about these complications was performed, analyzing data of subjects receiving versus not-receiving concomitant CABG. Primary outcome was early mortality. Secondary outcome was late mortality for hospital survivors. Subgroup analysis for VSR, LVFWR and PMR was also performed. Thirty-six studies were identified, including 4,321 patients (mostly VSR-related). Preoperative coronarography was performed in 92.2% of the cases, showing single-vessel disease in 54.3% of patients. Concomitant CABG rate was 49.0%. Early mortality was 32.6% and late mortality was 40.0% with 5.2 years of mean follow-up. The analysis showed no difference in early (OR 0.96; P=0.60) or late mortality (RR 0.91; P=0.49) between CABG and non-CABG group. In subgroup analysis, concomitant CABG was associated with significantly lower mortality at long term for PMR (RR 0.42; P=0.001), although it showed a higher, but not significant, mortality in VSR (RR 1.24; P=0.20). Concomitant CABG in the treatment for post-infarction mechanical complications showed no significant impact on both early and late mortality, although deserving some distinctions among different types of complication and single versus multiple vessel disease. However, larger, dedicated studies are required to provide more consistent data and evidence.

The Place of Conservative Treatment for Right Ventricular Free Wall Rupture after Acute Myocardial Infarction

Cardiac rupture is a rare but fatal complication of acute myocardial infarction (AMI), often with devastating hemodynamic consequences. Although the incidence has been reduced with the practice of reperfusion therapy, it still carries a high mortality rate of over 50%. Isolated right ventricular free wall rupture (RVFWR) is a rare entity with very few previously reported cases, and survival after RVFWR due to ST-segment elevation myocardial infarction (STEMI) treated with a conservative therapeutic strategy is extremely rare. Here, we presented two cases of RVFWR secondary to AMI, treated conservatively and survived.

Mechanical complications after myocardial infarction in a National Reference Hospital

To determine the clinical characteristics, therapeutic and in-hospital mortality of patients with mechanical complications post myocardial infarction. Observational, descriptive and retrospective study. We included patients >18 years old with a diagnosis of mechanical complication post myocardial infarction hospitalized at the Instituto Nacional Cardiovascular- INCOR in Lima -Peru, from January 1, 2017 to December 31, 2021. Variables like clinical characteristics, treatments, complications, and in-hospital mortality were studied. We found 37 cases, with a predominance of males (73.0%) and a median age of 73 years old. The location of the myocardial infarction was 51.4% in the anterior wall and 43.2% in the inferior wall. The patients received reperfusion therapy with fibrinolysis in 5 cases (13.5%), coronary angioplasty in 5 (13.5%), and 73% received only medical management prior to the diagnosis of mechanical complications. Of the 37 patients, 13 (35.1%) presented isolated ventricular free wall rupture, 12 (32.4%) isolated interventricular septum rupture, 10 (27.0%) the combination of ventricular free wall rupture and interventricular septum, and 2 (5.4%) papillary muscle rupture. In-hospital mortality was 51.4%. The ventricular free wall rupture was the most frequent complication, patients with mechanical complications after myocardial infarction still maintain high intra-hospital mortality rates, mainly in those who did not have adequate surgical treatment.

Thoracoscopic Trans-mitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy in the Elderly

BackgroundThe thoracoscopic trans-mitral approach can not only facilitate exposure of the ventricular septum, mitral valve, and subvalvular apparatus, it also enables the surgeons to perform concomitant mitral valve intervention. This study aimed to determine the safety and efficacy of thoracoscopic trans-mitral septal myectomy in elderly patients with hypertrophic obstructive cardiomyopathy (HOCM).MethodsWe reviewed the demographic to clinical characteristics and outcomes of patients who underwent thoracoscopic trans-mitral septal myectomy in our center between April 2019 and April 2021. The population was divided into a younger group (<60 years) and an elderly group (≥60 years).ResultsThere were 46 and 20 patients in the younger and elderly groups, respectively. The majority of patients in the elderly group were female (39.1 vs. 80.0%, P < 0.01). Patients in the elderly group were more likely to be in New York Heart Association Class IV (2.2 vs. 80.0%, P < 0.01). The European System for Cardiac Operation Risk Evaluation II predicted mortality rates were significantly higher (3.97 ± 1.81 vs. 1.62 ± 0.86%, P < 0.01) in the elderly group. In the elderly group, a patient converted to median sternotomy due to left ventricular posterior free wall rupture following septal myectomy and mitral bioprosthetic valve replacement. The patient then underwent double-patch sandwich repair for rupture and mitral mechanical valve replacement and was eventually discharged. All patients in the elderly group were discharged, while one in the younger group died. No patient in the elderly group required permanent pacemaker implantation vs. one in the younger group. Patients in the elderly group were more likely to spend more time in the intensive care unit than those in the younger group (5.44 ± 5.80 days vs. 3.07 ± 2.72, P < 0.05). However, there was no significant intergroup difference in in-hospital mortality or complications. Importantly, the left ventricular outflow tract pressure gradient was significantly decreased from 96.15 ± 32.89 mmHg to 8.2 ± 3.42 mmHg with no residual obstruction in the elderly group. The interventricular septal thickness was significantly decreased from 19.73 ± 3.14 mm to 11.30 ± 2.23 mm. Postoperative mitral regurgitation severity was significantly improved in the elderly group.ConclusionThis study demonstrated that thoracoscopic trans-mitral septal myectomy is a feasible option for selected elderly patients with satisfactory outcomes similar to those of young patients.

Mechanical complications of acute myocardial infarction: from diagnosis to treatment

Post-infarction mechanical complications include left ventricular free-wall rupture, ventricular septal rupture, and papillary muscle rupture. With the advent of early reperfusion strategies, including thrombolysis and percutaneous coronary intervention, these events now occur in fewer than 0.3% of patients following acute myocardial infarction. However, unfortunately, there has been no parallel decrease in associated mortality rates over the past two decades. Moreover, during the ongoing COVID-19 pandemic the incidence of mechanical complications resulting from ST-elevation myocardial infarction has possibly risen. Early diagnosis and prompt management are crucial to improving outcomes. Although some percutaneous device repair approaches are available, surgical treatment remains the gold standard for these catastrophic post-infarction complications. The timing of surgery, also related to the type of complication and patient's clinical conditions, and the possible role of mechanical circulatory supports before and after surgery, represent main topics of debate that still need to be fully addressed.

A Case of Left Ventricular Free Wall Rupture with Suspected Posterior Papillary Muscle Necrosis

A Case of Left Ventricular Free Wall Rupture with Suspected Posterior Papillary Muscle Necrosis