Acute inferior myocardial infarction combined with papillary muscle rupture: A case report. / 急性下壁心肌梗死合并乳头肌断裂1例.

The incidence of acute myocardial infarction (AMI) is increasing. Acute papillary muscle rupture is one of the serious and rare mechanical complications of AMI, which occurs mostly in inferior and posterior myocardial infarction. A patient with acute inferior myocardial infarction developed pulmonary edema and refractory shock, followed by cardiac arrest. After cardiopulmonary resuscitation (CPR), revascularization of criminal vessels was carried out by emergency percutaneous transluminal coronary angioplasty (PTCA) under the support of intra-aortic balloon pump (IABP) and extra corporeal membrane oxygenation (ECMO). Although the patient was given a chance for surgery, his family gave up treatment due to unsuccessful brain resuscitation. It reminds that mechanical complications such as acute papillary muscle rupture, valvular dysfunction and rupture of the heart should be highly suspected when cardiogenic pulmonary edema and cardiogenic shock are difficult to correct in acute inferior myocardial infarction. Echocardiogram and surgery should be put forward when revascularization of criminal vessels is available.

Successful percutaneous coronary intervention with extracorporeal membrane oxygenation in a patient with acute inferior wall myocardial infarction complicated by electrical storm, cardiogenic shock, and cardiac arrest: a case report.

BACKGROUND: High-risk patients with coronary heart disease who develop acute myocardial infarction (AMI) have severe coronary lesions. If severe complications occur, such as malignant ventricular arrhythmia, cardiogenic shock, and cardiac arrest, implementation of emergency percutaneous coronary intervention (PCI) may be hindered, leading to a higher perioperative mortality rate. Extracorporeal membrane oxygenation (ECMO) can pave the way for rapid myocardial reperfusion therapy. When cardiac arrest occurs, hemodynamic support with ECMO can facilitate revascularization with PCI, which can increase the time available for further salvage and treatment and reduce intraoperative risk during PCI. CASE PRESENTATION: Herein, we report a case of a 61-year-old man with AMI who suffered electrical storm of sustained malignant ventricular fibrillation, cardiogenic shock, and cardiac arrest and was successfully treated with PCI with ECMO support. During PCI, repeated aspiration and removal of the right coronary artery thrombus were performed, and blood flow was restored after right coronary artery balloon dilation. One episode of defibrillation was delivered to restore sinus rhythm. Then, stents were implanted in the distal and proximal right coronary artery lesions to achieve revascularization. After PCI with ECMO support, irreversible malignant arrhythmia returned to sinus rhythm through coronary perfusion, which prevented death following unsuccessful cardiopulmonary resuscitation. After applying active treatments, including anti-shock, mechanical ventilation, anti-inflammation, and organ support, the patient was discharged after his condition and vital signs stabilized. The patient was followed up once a week after hospital discharge, and his cardiopulmonary function recovered well. CONCLUSIONS: With ECMO support, PCI should be performed immediately in patients with inferior wall AMI complicated by electrical storm of sustained ventricular fibrillation, cardiogenic shock, and cardiac arrest to facilitate stent placement, achieve complete revascularization, restore coronary perfusion, and avoid death.

Left Ventricular Aneurysm After Post-Infarction Ventricular Septal Defect Repair.

The surgical indication and optimal approach for ischemic mitral regurgitation with ventricular septal defect remain uncertain. Very few studies have reported the occurrence of left ventricular aneurysms after repair of ischemic ventricular septal defects. We report a case of a left posterior ventricular aneurysm that developed after an urgent operation to repair an acute ischemic posterior ventricular septal defect using the double-patch sandwich technique via a right ventriculotomy.

[Inferior myocardial infarction complicated by complete heart block and cardiac arrest following a gadolinium injection: A case of Kounis syndrome]. / Infarctus du myocarde inférieur compliqué de bloc auriculo-ventriculaire complet et d'arrêt cardiocirculatoire dans les suites d'une injection de gadolinium : à propos d'une observation de syndrome de Kounis.

Kounis syndrome is an allergic acute coronary syndrome. It occurs on healthy or pathological arteries. Its complications, although often benign, can lead to cardiac arrest and death. Its triggering factors are multiple and include contrast products used in diagnostic imaging. We report the case of an 81 years old patient affected by hepatocellular carcinoma, who presented a type 2 Kounis syndrome with inferior myocardial infarction, complicated by cardiac arrest related to complete heart block following a gadoteric acid injection.

A Case of Post Myocardial Infarction Papillary Muscle Rupture.

Papillary muscle rupture is a rare, life-threatening post myocardial infarction mechanical complication. Without surgical intervention, prognosis is very poor. Clinicians need to recognize this complication early, as prompt therapy is crucial. We present a case of inferior ST elevation myocardial infarction complicated by posteromedial papillary muscle rupture resulting in severe acute mitral regurgitation (flail anterior mitral leaflet), acute pulmonary edema and cardiogenic shock. In our patient, a new mitral regurgitation murmur suggested this mechanical complication. Complete disruption of papillary muscle was visualized by transesophageal echocardiography. This case illustrates the importance of good physical examination for early diagnosis of papillary muscle rupture, so that life-saving treatment can be administered without delay.

The novel use of heart transplantation for the management of a case with multiple complications after acute myocardial infarction.

Rupture of the interventricular septum after myocardial infarction (MI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is usually the only definitive treatment for these patients because medical management is associated with a 30-day mortality approaching 100%. However with conventional surgical repair, operative mortality rates range from 33% to 53%. Furthermore, outcomes in patients with posterior ventricular septal defect (VSD) have been reported to have mortality rates up to 86%. Therefore, alternative treatment should be considered to improve management of this mechanical complication. We report the case of a 63-year-old man in whom VSD developed after an inferior MI. The patient presented with shortness of breath and a recent ST-elevation inferior MI. Transthoracic echocardiography revealed a 50% left ventricular ejection fraction with mild-moderate right ventricular dysfunction. A posterior VSD (diameter ≥ 12 mm), moderate ischemic mitral regurgitation (MR), and a posterior pseudoaneurysm were also seen. The operative risk was considered to be too high for VSD repair because the surgery would have to include bypass grafting, mitral valve replacement, and pseudoaneurysm correction. Consequently, an urgent heart transplantation was considered the best option. The patient underwent heart transplantation 9 days after initial symptoms, and the recovery was unremarkable. To achieve a definitive optimal treatment, we propose that patients with posterior VSD with significant MR or pseudoaneurysm, or both, should be considered as heart transplant candidates.

Assessment of right ventricular functional recovery after acute myocardial infarction by 2D speckle-tracking echocardiography.

To assess the pattern of right ventricular (RV) functional recovery in a cohort of patients with successful reperfusion of a first episode of acute myocardial infarction (AMI) with 2D speckle-tracking echocardiography and cardiac magnetic resonance imaging (CMR). Ninety-five revascularized AMI patients were prospectively included (56.8 ± 11.1 years, 48 inferior, 47 anterior). RV function was assessed by echocardiography and CMR within the initial 72 h and 6 months later. A RV global strain was calculated while averaging strain values from septal, lateral and inferior walls. At the acute phase, RVEFCMR was lower in inferior than in anterior AMI patients (52.5 ± 6.8 vs. 56.0 ± 4.8, p = 0.006). Similarly, RV global, inferior and lateral strains were lower in inferior MI patients (p < 0.001 for all) whereas septal strain was not significantly different across groups. At 6 months, RVEFCMR and all strain parameters improved compared to baseline. Improvements were more substantial for patients with inferior than with anterior MI. RV parameters ultimately reached similar levels in the two groups at 6 months except for inferior strain which remained lower in patients with inferior MI (-24.5 ± 6.5 vs. -27.5 ± 5.4, p = 0.03). In low risk patients after AMI, RV function ultimately recovered over the 6 months of follow up. Higher levels of both initial impairment and subsequent recovery were observed for inferior MI. Although RV function was relatively preserved in these patients, RV strain analysis revealed a persistent impairment of RV inferior strain in patients with inferior MI, which may not be identified by RVEFCMR or conventional echocardiographic parameters.

Transcatheter closure of residual postinfarction ventricular septal defect after dehiscence of surgical patch repair.

Ventricular septal defect (VSD) is a life-threatening complication of transmural myocardial infarction. Urgent surgical repair and concomitant revascularization are the standard of care. Percutaneous catheter-based closure techniques have been reserved for patients with a high-risk surgery or a failed surgical procedure with residual shunting. This case report demonstrates the successful transcatheter closure of residual VSD using the Amplatzer muscular VSD device (Amplatzer, Minnesota, USA) after surgical patch dehiscence for postinfarction VSD and 3-and-a-half years' post-intervention follow-up.

Emergências hipertensivas como manifestação clínica inicial de síndrome coronariana aguda / Hypertensive emergencies as the initial clinical manifestation of acute coronary syndrome

Relata-se uma série de três pacientes idosos, apresentando hipertensão arterial e coronariopatia crônica,assintomáticos e clinicamente controlados até o início das alterações tensionais súbitas que marcaram o início da evolução do evento coronariano. Foram realizados ECG, enzimas cardíacas seriadas, raios-X de tórax eecocardiograma, optando-se por cineangiocoronariografia. Em todos os pacientes observou-se ausência de estresse emocional/físico exorbitante ou perda da adesão ao tratamento, ausência de precordialgia, presença de lesões obstrutivas críticas, com presença de trombos em vasos de grande relevância anatômica e funcional (artéria culpada), com retorno à estabilização pressórica anterior após correção da isquemia por angioplastia coronariana.

Usefulness of gated SPECT myocardial imaging in evaluation of patients with inferior myocardial infarction.

OBJECTIVE: Gated single photon emission computed tomography (gated SPECT) myocardial imaging gives useful information about the extent and severity of perfusion abnormalities (PA) and global left ventricular (LV) function in patients with coronary artery disease. The aim of this study was to evaluate by gated SPECT myocardial imaging differences in perfusion scores and LV function between stress and rest in patients with mild left ventricular dysfunction and/or normal function and previous inferior myocardial infarction (IMI) and to detect myocardial stunning. MATERIALS AND METHODS: The study included 77 patients (age 53 ± 8.21) with mild left ventricular dysfunction and previous IMI divided into two groups. Group 1 consisted of 34 patients with IMI and additional ischemia on perfusion scan and group 2 with 43 patients with previous IMI without ischemia on perfusion scan. All patients underwent a 2-day stress-rest gated SPECT myocardial imaging protocol with 99m technetium-methoxyisobutylisonitrile ((99m)Tc-MIBI). RESULTS: There was a more significant post-stress to rest decrease in ejection fraction (EFps) in patients with IMI and additional ischemia (group 1) than in patients with IMI (group 2) (-1.5 ± 2.5 vs. 1.5 ± 2.3, p < 0.001). In group 1, there was a significant increase in post-stress end-systolic volume (ESVps) in comparison to ESVr (70.4 ± 29.8 vs. 66.2 ± 26.2 ml, p = 0.044). However, the decrease in EF post-stress to rest did not reach the level of significance (51.7 ± 10.8 vs. 53.2 ± 10.2%, p = 0.147). The extent and severity of perfusion abnormalities were higher on stress (SSS) than on rest images (SRS) (13.9 ± 8.6 vs. 8.3 ± 7.8, p < 0.001). There was no difference in global LV parameters or perfusion abnormalities in patients in group 2 between stress and rest except for a significant increase in the post-stress EF to rest value (57.9 ± 11.9 vs. 56.2 ± 10.5%, p = 0.018). Severe decrease of post-stress EF to rest was found in 12 (16%) patients indicating stunning. CONCLUSION: In patients with mild left ventricular dysfunction and IMI with additional ischemia there is evidence of a decrease in the post-stress EF with an increase in the post-stress ESV. In addition, a significant association between the decrease of post-stress EF with the extent and severity of perfusion abnormalities was detected. Gated SPECT myocardial imaging has an important role in the evaluation of perfusion and LV function in patients with IMI especially in patients with additional ischemia.

Post-infarction ventricular septal defect: triggered by Valsalva manoeuvre?

Post-infarction ventricular septal defect (VSD) is a fatal mechanical complication of myocardial infarction. Although the incidence has decreased to less than 1% after the extensive use of reperfusion strategies, post-infarction VSD still carries a high mortality risk. Management is controversial, whether to wait for surgery after a stabilisation period or to perform emergency surgery when diagnosed. We report on a case of post-infarction VSD that was detected with severe haemodynamic instability, beginning immediately after the patient's Valsalva manoeuvre on the sixth day of a non-reperfused inferior myocardial infarction. In the early period, the post-infarction VSD was repaired via a trans-aneurismal approach.

Echocardiographic progression of a subepicardial aneurysm after inferior myocardial infarction.

A 62-year-old man presented to hospital with chest oppression. Coronary angiography revealed total occlusion of the right coronary artery and inferior myocardial infarction was diagnosed. He was treated by percutaneous coronary intervention with stenting for myocardial infarction. After four months, echocardiography revealed a huge aneurysm protruding below the inferior surface of the left ventricle. It was considered to be a pseudoaneurysm from the echocardiographic findings. The patient had no symptoms and he refused surgery, so progression of the aneurysm was monitored carefully. At seven months after revascularization, the aneurysm showed a marked increase in size, with a maximal diameter of 48 mm and orifice diameter of 22 mm. Accordingly, the patient agreed to undergo surgical excision. The aneurysm was resected and the defect was closed with a pericardial patch. Pathological examination revealed all of the myocardial elements in the aneurysm wall and thrombus in its lumen. In conclusion, this was a rare case of ventricular subepicardial aneurysm.