2010 Euroecho Mechanical Complications MI

EUROECHO CONGRESS COPENHAGEN

TEACHING COURSE 2010

M. Joo Andrade, Lisbon PT

Echo in Emergencies

Mechanical Complications

of Acute Myocardial Infarction

Free wall rupture and pseudoaneurysm

Ventricular septal rupture

Acute MR (papillary muscle displacement or rupture)

RV infarction

Infarct expansion, aneurysm, LV remodeling

Thrombus

Complications of Acute MI



Cardiac Rupture



Transmural

AMI

Papillary

muscleIVS

LV free

wall

The wavefront of cell death

Incidence 1 - 4%

Accounts for up to 20% of deaths

Reduced by early revascularization

Late thrombolytic therapy accelerates the onset

Prevention is likely the most effective therapy

Characteristics of pts First episode of AMI (90%), no previous angina

More frequently female

Older than 55 years

Pre-existing hypertension

Association with single-vessel disease

and paucity of collateral vessels

Delayed hospitalization (>24h)

Cardiac Rupture



50% < 5 days

>90% within 15 days

Mechanical complications after PCI in STEMI

APEX-AMI



French JK et al. Am J Cardiol 2010; 105:59-63

Pro

po

rtio

n s

urv

ivin

gSurvival after mechanical complication

Days post-complication or post-randomization

No mechanical complication

Acute mitral regurgitation

15 (0,26%)

Free wall rupture

30 (0,52%)

Ventricular septal rupture

10 (0,17%)

52 of 5,745 pts(0,91%)

23,5 h after symptoms onset

73%

37%

20%

Free-wall Rupture - Presentation



Acute blowout formRapid haemodynamic collapse resulting from severe hypotension and

electromechanical dissociation secondary to cardiac tamponade

Cardiopulmonary resuscitation maneuvers unsuccessful

Subacute oozing form in up to 1/3 of the casesVentricular perforation sealed by organized thrombus and the pericardiumMay evolve over hours or even days

Patients may remain asymptomatic and haemodynamically stable

Presents mainly with pericardial effusion related signs and symptoms:recurrent or persistent chest pain (pericardial pain)

unprovoked emesis, restlessness and agitation

abrupt, transient hypotension and bradycardia or hemodynamic instability

syncope

a deviation of the ST and/or T wave from the usual evolutionary pattern after

AMI

69 y-old man

late reperfused inferior MI

Subacute free wall rupture

Raposo L, Andrade MJ et al

Cardiovascular Ultrasound 2006, 4:46EUROECHO CONGRESS

COPENHAGEN




Raposo L, Andrade MJ et al

Cardiovascular Ultrasound 2006, 4:46

Inferior wall MI with rupture

Haematic pericardial effusion

with thrombi /blood cloths

Impending tamponade

Surgical Findings

Subacute free wall rupture



Gomes R, Andrade MJ et al


Left ventricular pseudoaneurysm

Echo features

Sharp discontinuity of the endocardial edge

Globular contour of the pseudoaneurysm

Relative narrow neck

Expansion during systole



Gomes R, Andrade MJ et al


Left ventricular pseudoaneurysm

Doppler flow between the LV cavity and pseudoaneurysm:into the pseudoaneurysm beginning in late diastole

back into the LV beginning in late systole and ending in early-mid diastole



Acute MR and IVS rupture

IncidencePre-thrombolytic era: 1-2%

Overall incidence reduced by early reperfusion strategies

GUSTO-I: Acute MR 1.7; IVS Rupture 0.2%Crenshaw. Circulation 2000;101:27.

SHOCK Trial Registry: Acute MR 6.9%; IVS Rupture 3.9%Hochman. J Am Coll Cardiol 2000;36:1063.

Clinical ProfileDemographics: advanced age and female

Past history: hypertension

MI location: Acute MR inferior; IVS Rupture anterior

TimingOld reports: 3 to 5 days

Reperfusion therapy shifted the occurrence to early after MI

GUSTO-I: median 1 day

SHOCK Trial Registry: median 22h (AMR), 16h (IVS)

IVS Rupture Pathophysiology

LocationApical: anterior MI Basal: inferior MI

Multiple: 40% Direct/simple VS Serpiginous/Complex

Associated CADMultivessel disease: 51% GUSTO-I; 74% SHOCK Trial Registry

Total occlusion of the IRA with poor collaterals

Magnitude of Left-to-Right Shunt Determined by the size of the defect

Determines the extent of haemodynamic compromise



Acute MR Pathophysiology

LocationPostero-medial papillary muscle (PD): 75%

Antero-lateral papillary muscle (LAD + LCX): 25%

Partial (2/3) >> Complete rupture (1/3)

Small infarcts: 50%

Associated CADMultivessel disease: 40%

Magnitude of Mitral RegurgitationDetermined by the extent of papillary muscle rupture

Determines the extent of haemodynamic compromise



Acute MR and IVS rupture Clinical Presentation

Acute

Pulmonary

Oedema

Cardiogenic

Shock

Physical Examination



The degree of haemodynamic instability

The most important predictor of outcome

Acute MR IVS rupture

Systolic murmur 50% 90%

Thrill no 50%

Diagnosis and management PA Catheter

Acute MR

50

40

30

20

10

IVS RuptureRA O2 Sat = 71%

75

60

45

30

15

PA O2 Sat = 93%



Acute MR and IVS rupture



Ventricular Septal Rupture - TTE



Ventricular Septal Rupture TTEDoppler measurements

E/E=18

RV/RA Peak grad

LV/RV Peak grad QP:QS



IVS Rupture TEE

IVS Rupture Intra-operative TEE



Courtesy of J Almeida, Oporto



Papillary Muscle Rupture - TEE



Mitral regurgitation - TTE

Papillary Muscle Rupture - TTE



After mitral valve replacement



Acute MR and IVS Rupture

while emergency surgery is being arranged

Vasodilators: Nitroprusside, nitroglycerin

Inotropic agents: Dobutamine

Intra-aortic balloon counterpulsation

Mechanical ventilation

Goals magnitude regurgitation/shunt

systemic perfusion

ventricular performance

Management Medical Treatment



Levine, R. A. N Engl J Med 2004;351:1681-1684

Ischaemic mitral regurgitation






Mild Mitral Regurgitation after MI is a significant

predictor for 1-year all-cause mortality

Feinberg M et al. Am J Cardiol 2000; 86:903-907Francesca Bursi et al. Circulation 2005; 111:295-301

Mitral Regurgitation after AMI portends an adverse

prognosis with increased risk of death



Indications for surgery in ischaemic MR



Left ventricular aneurysm

Complications

Treatment

Incidence (8-15%)

Differential diagnosis (pseudoaneurysm)

indications for surgical repair

HF, sustained VT, arterial embolism



Left ventricular aneurysm

Surgical repair

Courtesy of J Almeida, Oporto

Left ventricular thrombus





RV infarction



LV Remodeling after AMI



Predictors of LV Remodeling after AMI

Pre-existing hypertension

Infarct size Large asynergic zone (high WMSi)

Cardiac enzyme index Ejection Fraction

Anterior location Infarct expansion

Transmurality of infarction

End-systolic volume Short early mitral DT

Patency of the IRA TIMI grade

No dyssynchrony at baseline

No remodeling at follow-up

Dyssynchrony at baseline

Remodeling at follow-up

Mollema et al. J Am Coll Cardiol 2007; 50:1532

LV Dyssynchrony acutely after MI

predicts LV remodeling



TT Coronary Flow Reserve after Successful P-PTCA for Acute anterior MI is an Independent Predictor

of LV Recovery and in-hospital CE

Meimoun P et al. J Am Soc Echocardiogr 2009;22:1071-9

best cutoff for CFR = 1.7

r=0.63

P

Conclusions



Echocardiography is a standard tool in the management

of patients with AMI

Emergent bedside echo is mandatory in case of sudden

haemodynamic deterioration

Echocardiography is able to fully diagnose mechanical

complications of AMI

Echo in the unstable patient with AMI is a highly

demanding procedure to be performed by experient

professionals

Documents

2010 Euroecho Mechanical Complications MI