Extracorporeal life support in mitral papillary muscle rupture: Outcome of multicenter study.

BACKGROUND: Post-acute myocardial infarction papillary muscle rupture (post-AMI PMR) may present variable clinical scenarios and degree of emergency due to result of cardiogenic shock. Veno-arterial extracorporeal life support (V-A ECLS) has been proposed to improve extremely poor pre- or postoperative conditions. Information in this respect is scarce. METHODS: From the CAUTION (meChanical complicAtion of acUte myocardial infarcTion: an InternatiOnal multiceNter cohort study) database (16 different Centers, data from 2001 to 2018), we extracted adult patients who were surgically treated for post-AMI PMR and underwent pre- or/and postoperative V-A ECLS support. The end-points of this study were in-hospital survival and ECLS complications. RESULTS: From a total of 214 post-AMI PMR patients submitted to surgery, V-A ECLS was instituted in 23 (11%) patients. The median age was 61.7 years (range 46-81 years). Preoperatively, ECLS was commenced in 10 patients (43.5%), whereas intra/postoperative in the remaining 13. The most common V-A ECLS indication was post-cardiotomy shock, followed by preoperative cardiogenic shock and cardiac arrest. The median duration of V-A ECLS was 4 days. V-A ECLS complications occurred in more than half of the patients. Overall, in-hospital mortality was 39.2% (9/23), compared to 22% (42/219) for the non-ECLS group. CONCLUSIONS: In post-AMI PMR patients, V-A ECLS was used in almost 10% of the patients either to promote bridge to surgery or as postoperative support. Further investigations are required to better evaluate a potential for increased use and its effects of V-A ECLS in such a context based on the still high perioperative mortality.

Permanent pacemaker implantation following transcatheter aortic valve implantation using self-expandable, balloon-expandable, or mechanically expandable devices: a network meta-analysis.

AIMS: Permanent pacemaker implantation (PPI) still limits the expansion of indications for transcatheter aortic valve implantation (TAVI). Comparison between different systems remains scarce. We aimed to determine the impact of the device type used on post-TAVI PPI. METHODS AND RESULTS: A systematic literature review was performed to identify studies reporting the use of balloon-expandable valve (BEV), self-expandable valve (SEV), and mechanically expandable valve (MEV) and post-TAVI PPI. A network meta-analysis was used to compare TAVI mechanisms (Analysis A) and transcatheter heart valves (Analysis B) with respect to post-TAVI PPI. Analysis A included 40 181 patients with a pooled PPI rate of 19.2% in BEV, 24.7% in SEV, and 34.8% in MEV. Balloon-expandable valve showed lower risk compared to either SEV or MEV and SEV demonstrated lower risk for PPI than MEV. Implantation of BEV was associated with 39% and 62% lower PPI rate with respect to SEV and MEV. Implantation of SEV was associated with 38% lower PPI rate with respect to MEV. Analysis B included 36.143 patients with the lowest pooled PPI rate of 9.6% for Acurate Neo or others, and the highest pooled PPI rate of 34.3% for Lotus. CoreValve, Evolut Portico, and Lotus influenced significantly PPI rate, while Sapien group did not. CONCLUSION: Implantation of BEV and also SEV were associated with lower post-TAVI PPI rate, while MEV were associated with higher post-TAVI PPI. Patient tailored-approach including devices characteristics may help to reduce post-TAVI PPI and to allow TAVI to take the leap towards extension of use in younger patients. PROSPERO NUMBER: CRD42021238671.

Meta-analysis of surgical treatment for postinfarction left ventricular free-wall rupture.

BACKGROUND: Left ventricular free-wall rupture (LVFWR) is one of the most lethal complications after acute myocardial infarction (AMI). The optimal therapeutic strategy is controversial. The current meta-analysis sought to examine the outcome of patients surgically treated for post-AMI LVFWR. METHODS: A comprehensive literature review was performed to identify articles reporting outcomes of subjects who underwent LVFWR surgical repair. The primary endpoint was operative mortality. A meta-analysis was performed to assess the associations of predefined variables of interest and clinical prognosis. RESULTS: Of the 3132 retrieved articles, 11 nonrandomized studies, enrolling a total of 363 patients, fulfilled the inclusion criteria and were included in this analysis. The mean age of patients was 68 years. The operative mortality rate was 32% (n = 115). Meta-analysis revealed reduced operative risk in patients with oozing type rupture, as compared to blowout type (risk ratios [RR]: 0.47; 95% confidence interval [CI]: 0.33-0.67; p < .0001); RR was also significantly reduced in subjects in whom LVFWR was treated with sutureless technique, as compared to those undergoing sutured repair (RR: 0.59; 95% CI: 0.41-0.83; p = .002). Increased risk of operative mortality was demonstrated in patients who required postoperative extracorporeal membrane oxygenation (ECMO) support (RR: 2.39; 95% CI: 1.59-3.60; p < .0001). CONCLUSIONS: Surgical treatment of postinfarction LVFWR has a high operative mortality rate. Blowout rupture, sutured repair and postoperative ECMO support are factors associated with increased risk of operative mortality.

Surgical treatment of primary cardiac tumors in the contemporary era: A single-centre analysis.

BACKGROUND: Primary cardiac tumors (PCT) are rare lesions but have the potential to cause significant morbidity if not timely treated. We reviewed our single-center experience in the surgical treatment of PCT with a focus on the long-term outcome. METHODS: From 2001 to 2020, 57 consecutive patients underwent surgical resection of PCT at our Institution. Data including the demographic characteristics, tumor histology, surgical procedure, and postoperative outcomes were collected and analyzed. RESULTS: Mean age at presentation was 63.6 ± 11.2 years, and 33 (57.9%) of the patients were female. A total of 55 (96.5%) subjects were diagnosed with benign cardiac tumor, while the remaining had malignant tumors. The most common histopathological type was myxoma. All patients survived to hospital discharge. Main postoperative complications were: acute kidney injury (n = 3), sepsis (n = 3), and stroke (n = 2). Mean follow-up time was 9 ± 5.9 years. Long-term mortality was 22.8% (13/57). No tumor recurrence was observed among survivors. There was a significant relationship between mortality and pathological characteristics of the tumor, and myxomas had higher survival rates. CONCLUSION: Surgical treatment of PCT is a safe and highly effective strategy associated with excellent short-term outcomes. Long-term survival remains poor for primary malignant tumors of the heart.

Ventricular Pseudoaneurysm and Free Wall Rupture After Acute Myocardial Infarction: JACC Focus Seminar 4/5.

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review.

Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5.

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.

Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5.

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.

Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry.

BACKGROUND: Surgical ablation for atrial fibrillation at the time of isolated coronary artery bypass grafting is reluctantly attempted. Meanwhile, complete revascularization is not always possible in these patients. We attempted to counterbalance the long-term benefits of surgical ablation against the risks of incomplete revascularization. METHODS: Atrial fibrillation patients undergoing isolated coronary artery bypass grafting for multivessel disease between 2012 to 2022 and included in the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry were divided into complete revascularization, complete revascularization with additional grafts, and incomplete revascularization cohorts; these were further split into surgical ablation and non-surgical ablation subgroups. RESULTS: A total of 8,405 patients (78% men; age 69.3 ± 7.9) were included; of those, 5,918 (70.4%) had complete revascularization, and 556 (6.6%) had surgical ablation performed. Number of anastomoses was 2.7 ± 1.2. The median follow-up was 5.1 [interquartile range 2.1-8.8] years. In patients in whom complete revascularization was achieved, surgical ablation was associated with long-term survival benefit: hazard ratio 0.69; 95% confidence intervals (0.50-0.94); P = .020 compared with grafting additional lesions. Similarly, in patients in whom complete revascularization was not achieved, surgical ablation was associated with a long-term survival benefit of 0.68 (0.49-0.94); P = .019. When comparing surgical ablation on top of incomplete revascularization against complete revascularization without additional grafts or surgical ablation, there was no difference between the 2: 0.84 (0.61-1.17); P = .307, which was also consistent in the propensity score-matched analysis: 0.75 (0.39-1.43); P = .379. CONCLUSION: To achieve complete revascularization is of utmost importance. However, when facing incomplete revascularization at the time of coronary artery bypass grafting in a patient with underlying atrial fibrillation, concomitant surgical ablation on top of incomplete revascularization is associated with similar long-term survival as complete revascularization without surgical ablation.

Long-term survival after surgical treatment for post-infarction mechanical complications: results from the Caution study.

BACKGROUND AND AIMS: Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study early and long-term results of patients undergoing surgical treatment for post-AMI MCs. METHODS: Patients undergone surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centers worldwide were retrieved from the database of CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality. RESULTS: The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5 and 10 years was 54.0%, 48.1% and 41.0%, respectively. Older age (p < 0.001) and postoperative LCOS (p < 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significant higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022). CONCLUSIONS: Contemporary data from a multicenter cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate postoperative period is encouraging.Trial registration number: NCT03848429.

Biology of mitral valve prolapse: from general mechanisms to advanced molecular patterns-a narrative review.

Mitral valve prolapse (MVP) represents the most frequent cause of primary mitral regurgitation. For several years, biological mechanisms underlying this condition attracted the attention of investigators, trying to identify the pathways responsible for such a peculiar condition. In the last ten years, cardiovascular research has moved from general biological mechanisms to altered molecular pathways activation. Overexpression of TGF-ß signaling, for instance, was shown to play a key role in MVP, while angiotensin-II receptor blockade was found to limit MVP progression by acting on the same signaling pathway. Concerning extracellular matrix organization, the increased valvular interstitial cells density and dysregulated production of catalytic enzymes (matrix metalloproteinases above all) altering the homeostasis between collagen, elastin and proteoglycan components, have been shown to possibly provide a mechanistic basis contributing to the myxomatous MVP phenotype. Moreover, it has been observed that high levels of osteoprotegerin may contribute to the pathogenesis of MVP by increasing collagen deposition in degenerated mitral leaflets. Although MVP is believed to represent the result of multiple genetic pathways alterations, it is important to distinguish between syndromic and non-syndromic conditions. In the first case, such as in Marfan syndrome, the role of specific genes has been clearly identified, while in the latter a progressively increasing number of genetic loci have been thoroughly investigated. Moreover, genomics is gaining more interest as potential disease-causing genes and loci possibly associated with MVP progression and severity have been identified. Animal models could be of help in better understanding the molecular basis of MVP, possibly providing sufficient information to tackle specific mechanisms aimed at slowing down MVP progression, therefore developing non-surgical therapies impacting on the natural history of this condition. Although continuous progress has been made in this field, further translational studies are advocated to improve our knowledge of biological mechanisms underlying MVP development and progression.

Risk of Bias in Randomized Clinical Trials Comparing Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-analysis.

Importance: Recent European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines highlighted some concerns about the randomized clinical trials (RCTs) comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. Quantification of these biases has not been previously performed. Objective: To assess whether randomization protects RCTs comparing TAVI and SAVR from biases other than nonrandom allocation. Data Sources: A systematic review of the literature between January 1, 2007, and June 6, 2022, on MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was performed. Specialist websites were also checked for unpublished data. Study Selection: The study included RCTs with random allocation to TAVI or SAVR with a maximum 5-year follow-up. Data Extraction and Synthesis: Data extraction was performed by 2 independent investigators following the PRISMA guidelines. A random-effects meta-analysis was used for quantifying pooled rates and differential rates between treatments of deviation from random assigned treatment (DAT), loss to follow-up, and receipt of additional treatments. Main Outcomes and Measures: The primary outcomes were the proportion of DAT, loss to follow-up, and patients who were provided additional treatments and myocardial revascularization, together with their ratio between treatments. The measures were the pooled overall proportion of the primary outcomes and the risk ratio (RR) in the TAVI vs SAVR groups. Results: The search identified 8 eligible trials including 8849 participants randomly assigned to undergo TAVI (n = 4458) or SAVR (n = 4391). The pooled proportion of DAT among the sample was 4.2% (95% CI, 3.0%-5.6%), favoring TAVI (pooled RR vs SAVR, 0.16; 95% CI, 0.08-0.36; P < .001). The pooled proportion of loss to follow-up was 4.8% (95% CI, 2.7%-7.3%). Meta-regression showed a significant association between the proportion of participants lost to follow-up and follow-up time (slope, 0.042; 95% CI, 0.017-0.066; P < .001). There was an imbalance of loss to follow-up favoring TAVI (RR, 0.39; 95% CI, 0.28-0.55; P < .001). The pooled proportion of patients who had additional procedures was 10.4% (95% CI, 4.4%-18.5%): 4.6% (95% CI, 1.5%-9.3%) in the TAVI group and 16.5% (95% CI, 7.5%-28.1%) in the SAVR group (RR, 0.27; 95% CI, 0.15-0.50; P < .001). The imbalance between groups also favored TAVI for additional myocardial revascularization (RR, 0.40; 95% CI, 0.24-0.68; P < .001). Conclusions and Relevance: This study suggests that, in RCTs comparing TAVI vs SAVR, there are substantial proportions of DAT, loss to follow-up, and additional procedures together with systematic selective imbalance in the same direction characterized by significantly lower proportions of patients undergoing TAVI that might affect internal validity.

Surgical repair of postinfarction ventricular septal rupture: current state of the art.

The incidence of postacute myocardial infarction ventricular septal rupture (post-AMI VSR) has decreased over the past two decades. Nevertheless, individuals who suffer from post-AMI VSR continue to represent a subgroup of patients with high morbidity and mortality. The care for these patients is complex and requires a multidisciplinary approach. However, because of the small number of reports that exist to guide clinical practice, there is a significant variability in care among centers. This review summarizes information on post-AMI VSR diagnosis and outline contemporary best management and practice consideration.

Outcomes of Transcatheter Aortic Valve Implantation Comparing Medtronic's Evolut PRO and Evolut R: A Systematic Review and Meta-Analysis of Observational Studies.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become a broadly acceptable alternative to AV surgery in patients with aortic stenosis (AS). New valve designs are becoming available to address the shortcomings of their predecessors and improve clinical outcomes. METHODS: A systematic review and meta-analysis was carried out to compare Medtronic's Evolut PRO, a new valve, with the previous Evolut R design. Procedural, functional and clinical endpoints according to the VARC-2 criteria were assessed. RESULTS: Eleven observational studies involving N = 12,363 patients were included. Evolut PRO patients differed regarding age (p < 0.001), sex (p < 0.001) and STS-PROM estimated risk. There was no difference between the two devices in terms of TAVI-related early complications and clinical endpoints. A 35% reduction of the risk of moderate-to-severe paravalvular leak (PVL) favoring the Evolut PRO was observed (RR 0.66, 95%CI, [0.52, 0.86] p = 0.002; I2 = 0%). Similarly, Evolut PRO-treated patients demonstrated a reduction of over 35% in the risk of serious bleeding as compared with the Evolut R (RR 0.63, 95%CI, [0.41, 0.96]; p = 0.03; I2 = 39%), without differences in major vascular complications. CONCLUSIONS: The evidence shows good short-term outcomes of both the Evolut PRO and Evolut R prostheses, with no differences in clinical and procedural endpoints. The Evolut PRO was associated with a lower rate of moderate-to-severe PVL and major bleeding.

Atrial fibrillation ablation improves late survival after concomitant cardiac surgery.

OBJECTIVE: Preoperative atrial fibrillation (AF) increases risk of stroke, heart failure, and all-cause mortality after cardiac surgery. Despite encouraging results and guideline recommendations, surgical ablation (SA) for AF concomitant with other heart surgery remains low. In the current study we aimed to address the long-term mortality after SA concomitant with cardiac surgery. METHODS: This report pertains to the HEart surgery In atrial fibrillation and Supraventricular Tachycardia (HEIST) registry. We identified 20,765 adult patients (62% male) with preoperative AF who underwent conventional sternotomy heart surgery between 2010 and 2021 in 8 tertiary centers in Poland, Netherlands, and Italy. We used Cox proportional hazards models for computations and propensity score matching to minimize differences in baseline characteristics. RESULTS: Of included patients, 2755 (13.4%) underwent SA for AF. The highest rates of SA were observed for mitral interventions (mitral valve repair or replacement and tricuspid intervention, 25.2%), lowest for isolated coronary artery bypass grafting (6.2%). Patients in the SA group were younger (mean age 64.5 ± 9.0 years vs 68.7 ± 16.0 years; P < .001) and lower risk (mean European System for Cardiac Operative Risk Evaluation [EuroSCORE] II, 4.1 vs 5.7; P < .001). During the 11-year study period, there was a mortality reduction associated with SA (hazard ratio, 0.57; 95% CI, 0.52-0.62; P < .001). After propensity matching, 2750 pairs with similar baseline characteristics were identified. SA was associated with 16% mortality decline (hazard ratio, 0.84; 95% CI, 0.75-0.94; P = .003). CONCLUSIONS: In this multicenter, retrospective, propensity matched study, SA concomitant with other cardiac surgery was associated with improved long-term survival regardless of baseline surgical risk.

Impact of COVID-19 on incidence and outcomes of post-infarction mechanical complications in Europe.

OBJECTIVES: Post-acute myocardial infarction mechanical complications (post-AMI MCs) represent rare but life-threatening conditions, including free-wall rupture, ventricular septal rupture and papillary muscle rupture. During the coronavirus disease-19 (COVID-19) pandemic, an overwhelming pressure on healthcare systems led to delayed and potentially suboptimal treatments for time-dependent conditions. As AMI-related hospitalizations decreased, limited information is available whether higher rates of post-AMI MCs and related deaths occurred in this setting. This study was aimed to assess how COVID-19 in Europe has impacted the incidence, treatment and outcome of MCs. METHODS: The CAUTION-COVID19 study is a multicentre retrospective study collecting 175 patients with post-AMI MCs in 18 centres from 6 European countries, aimed to compare the incidence of such events, related patients' characteristics, and outcomes, between the first year of pandemic and the 2 previous years. RESULTS: A non-significant increase in MCs was observed [odds ratio (OR) = 1.15, 95% confidence interval (CI) 0.85-1.57; P = 0.364], with stronger growth in ventricular septal rupture diagnoses (OR = 1.43, 95% CI 0.95-2.18; P = 0.090). No significant differences in treatment types and mortality were found between the 2 periods. In-hospital mortality was 50.9% and was higher for conservatively managed cases (90.9%) and lower for surgical patients (44.0%). Patients admitted during COVID-19 more frequently had late-presenting infarction (OR = 2.47, 95% CI 1.24-4.92; P = 0.010), more stable conditions (OR = 2.61, 95% CI 1.27-5.35; P = 0.009) and higher EuroSCORE II (OR = 1.04, 95% CI 1.01-1.06; P = 0.006). CONCLUSIONS: A non-significant increase in MCs incidence occurred during the first year of COVID-19, characterized by a significantly higher rate of late-presenting infarction, stable conditions and EuroSCORE-II if compared to pre-pandemic data, without affecting treatment and mortality.

The current clinical practice for management of post-infarction ventricular septal rupture: a European survey.

Aims: Many historical and recent reports showed that post-infarction ventricular septal rupture (VSR) represents a life-threatening condition and the strategy to optimally manage it remains undefined. Therefore, disparate treatment policies among different centres with variable results are often described. We analysed data from European centres to capture the current clinical practice in VSR management. Methods and results: Thirty-nine centres belonging to eight European countries participated in a survey, filling a digital form of 38 questions from April to October 2022, to collect information about all the aspects of VSR treatment. Most centres encounter 1-5 VSR cases/year. Surgery remains the treatment of choice over percutaneous closure (71.8% vs. 28.2%). A delayed repair represents the preferred approach (87.2%). Haemodynamic conditions influence the management in almost all centres, although some try to achieve patients stabilization and delayed surgery even in cardiogenic shock. Although 33.3% of centres do not perform coronarography in unstable patients, revascularization approaches are widely variable. Most centres adopt mechanical circulatory support (MCS), mostly extracorporeal membrane oxygenation, especially pre-operatively to stabilize patients and achieve delayed repair. Post-operatively, such MCS are more often adopted in patients with ventricular dysfunction. Conclusion: In real-life, delayed surgery, regardless of the haemodynamic conditions, is the preferred strategy for VSR management in Europe. Extracorporeal membrane oxygenation is becoming the most frequently adopted MCS as bridge-to-operation. This survey provides a useful background to develop dedicated, prospective studies to strengthen the current evidence on VSR treatment and to help improving its currently unsatisfactory outcomes.

[Mechanical complications of acute myocardial infarction: from diagnosis to treatment]. / Le complicanze meccaniche dell'infarto miocardico acuto: dalla diagnosi al trattamento.

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.

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.