Complications of Infarction
Coronary - recurrent ischemia / infarction
Heart Failure - pump dysfunction, RV infarction
Arrhythmia - tachyarrhythmia, bradyarrhythmia
Pericardial - pericarditis, pericardial effusion
Intracavitary Thrombi - apical thrombus
Valvular - functional mitral regurgitation
Mechanical - freewall rupture, septal rupture, papillary muscle rupture, aneurysm, false anuerysm
Mechanical Complications of MI
Papillary muscle rupture
Ventricular Freewall Rupture
Occlusion of any of the three major coronary arteries supplying the freewall of either ventricle.
Left anterior descending artery (LAD)
Left circumflex (LCx)
Right coronary artery (RCA)
Transmural necrosis weakening the tissue, with sufficient force still being gneerated by the remainder of the ventricle to disrupt/rupture the necrotic muscle. Blood then rushes out into the pericardial space, you tamponade, and you die.
How Does a Freewall Rupture Happen?
Consequence of a transmural infarction (STEMI)
There is stress at a point between the normal myocardium and the dense, necrotic infarct (hinge point). Sometimes there may be a precipitant that surges the blood pressure such as a cough or straining.
Risk factors are age, female, first MI, use of NSAIDs, and late reperfusion.
This happens when tissue is necrotic (2-7 days post infarct).
What Happens in a Freewall Rupture?
Sudden transmission of LV cavitary blood (and pressure) into the pericardial space. The patient experiences abrupt hypotension often resulting in cardiogenic shock or cardiac arrest as this leads to a tamponade.
This can be preceded by a vagal reaction (nausea, bradycardia, cold diaphoresis)
Making the Diagnosis of Freewall Rupture
Get a STAT echocardiogram
If you see one, get them to the operating room immediately
Freewall Rupture - Treatment
Emergent surgical repair with patch closure
A minority survive. Patients with smaller tears and less severe compression of the heart are potentially salvageable, but the majority with large tears result in immediate death.
Caused by an occlusion of an artery supplying the ventricular septum.
Left anterior descending artery (LAD) (twice as often)
Right coronary artery (RCA)
Transmural necrosis weakening the tissue, while sufficient force is generated by the remainder of the ventricle to rupture the necrosed myocardium and result in shunting of blood from the LV into the RV.
What Happens in a Septal Rupture?
Left to right heart shunting of blood.
Usually more than half of the LV stroke volume is lost into the right heart, and forward output from the LV falls severely. Systemic hypoperfusion or shock develops. Increased flow in the lungs and left atrium increases pulmonary pressures, congesting the lungs.
Making the Diagnosis of a Septal Rupture
New pansystolic murmur
Bedside echocardiogram or cardiac catheterization
Septal Rupture - Treatment
Emergent surgical repair
About 50% salvage if operated
Rare survival without an operation
Unfortunately, this is a crummy situation. If you don't operate, the patient will die. But if you do operate, the patient will most likely die too. Particularly, the earlier you operate, the harder the operation is and the higher the complications because the tissue is necrotic.
Papillary Muscle Rupture
Occlusion of an artery supplying a papillary muscle.
Results in necrosis of the papillary muscle
Sufficient forces generated by the remainder of the LV to rupture partially or completely, a papillary muscle.
What Happens in Papillary Muscle Rupture?
Severe regurgitation of blood into the left atrium, raising left atrial and pulmonary venous pressure and causing immediate pulmonary edema.
Loss of stroke volume into the left atrium occurs at the expense of forward flow, and the systemic output of the heart falls which can lead to cardiogenic shock.
Making the Diagnosis of a Papillary Muscle Rupture
Clinical suspicion (murmur, low BP)
Diagnosed via echocardiography
Papilalry Muscle Rupture - Treatment
Surgical mitral valve replacement within 6 hours of occurrence (before the low output state results in irrepairable kidney failure)
Supportive care is not to delay surgery, merely to attempt to stabilize or improve before surgery.
Majority survive with good quality of life if operated on. The mortality rate if left un-operated is 85% within 48 hours.
Aneurysm - Definition
A localized widening (dilatation) of an artery, vein, or the heart. At the area of an aneurysm, there is typically a bulge and the wall is weakened and may ruptured.
Left Ventricular Aneurysm
Cause is from an occlusion of an artery resulting in transmural necrosis of the wall. Sufficient forces is generated by the remainder of the LV to distend/dilate the infarct territory.
If it dilates in diastole it is an aneurysm
If it further dilates in systole, it is a "dyskinesis"
What Happens in LV Aneurysm
Loss of contractile function by the transmural infarction reduces forward ejection fraction.
Systolic dilation of the infarct territory wastes/consumes potential stroke volume, further reducing forward ejection.
Stagnation of flow in the non-contractile infarct segment promotes local thrombosis, which has the potential of systemic embolization.
Making the Diagnosis of LV Aneurysm
Imaging such as echocardiogram.
Left Ventricular Aneurysm - Treatment
Medical therapy is the standard treatment. Particulary ACE inhibitors to prevent further remodelling of the heart.
Surgical aneurysmectomy may be performed as a secondary indication for open heart surgery. Doing surgery in and of itself for LV aneurysm has not been shown to have a mortality benefit.
Prognosis is a higher risk of heart failure.
"Contained" freewall rupture
Prior adhesive pericarditis which has caused fibrosis and tougher tissue.
Occlusion of a coronary artery resulting in transmural necrosis of the myocardium (STEMI). Sufficient forces generated by the remainder of the LV to result in rupture of the infarct territory.
The rupture through the myocardium is contained locally within the pericardial space.
What Happens in False Aneurysm?
Loss of systolic function by ejection into the body of the false aneurysm.
Stagnation of flow within the false aneurysm is conducive for thrombus formation, which can result in systemic embolization.
Eventually, local containment of the rupture can be lost, resulting in tamponade and death.
True vs. False Aneurysm
In a true aneurysm, all layers of the endocardium are out-pouched together.
In a false aneurysm, just the pericardium is out-pouched.
Sugical treatment repair with a patch.