Cardiogenic Shock & Mechanical

Complications of Myocard Infarction

NADIAR DWI NUARISA
BAMBANG HERWANTO

Department of Cardiology & Vascular Medicine

Dr. Sutomo Hospital Faculty of Medicine Airlangga University
Surabaya
2015

Introduction
Definition
Mechanical Complication of AMI

Ventricular Septal Rupture (VSR)

Acute Mitral Regurgitation
LV Free Wall Rupture
Management of Cardiogenic Shock in AMI
Prognosis
Summary

Introduction

Worldwide, coronary artery disease (CAD) is the single most frequent cause
of death. Over seven million people every year die from CAD

Cardiogenic shock is a serious complication of acute myocardial infarction

(AMI). Mortality is about 50%.

The mechanical complications of AMI are responsible for approximately

25,000 deaths per year in the US.

Since the introduction of PCI, the incidence of mechanical complications

reduced significantly to < 1%

Surgical evaluation should be performed early whenever there is suspicion

of a mechanical complication

Definition (WHO)

The definition was based on patient symptoms and ECG

findings

Combination of two of three characteristics:

1.

typical symptoms (i.e. chest discomfort)

2.

enzyme rise

3.

typical ECG pattern involving the development of Q

waves

But still myocardial infarction was mainly an ECG based

diagnosis

Definition of Cardiogenic Shock

Is a clinical condition of inadequate tissue (end-organ)

perfusion due to cardiac dysfunction

- hypotension ( SBP<90mmHg for 30 min, or the need for

supportive measures to maintain SBP90mmHg), fall of
MAP 30mmHg from baseline
- end-organ hypoperfusion (cool extremities or an urine
output<30 ml/h)
- a cardiac index (CI) < 1,8 l/m/m2 or < 2.2 l/min/m2
with haemodynamic support, and a pulmonary
capillary wedge pressure (PCWP)> 18 mmHg

Mechanical Complication of MI
Ventricular Septal Rupture (VSR)

VSR is lethal complication of acute myocardial infarction

(AMI)

Expected to occur within 16 hours after AMI. The

outcome are poor

Independent risk factors for VSR : hypertension, older

age, female gender, history of previous stroke, CKD, CHF,
diabetes, smoking, & previous MI.

VSR direct effect is the shunting of blood from LV to RV

cardiogenic shock

On physical examination we can found pansystolic loud murmur,

sounds most clearly at the left edge of the sternum, palpable
parasternal thrill

ECG recordings showed anterior or inferior STEMI with AV block

Doppler echocardiography is the gold standard for diagnosis

distinguish between papillary muscle rupture and VSR, assess RV &
LV function, identified size & site of rupture

Management of VSR (Jones et al, European Heart Journal 2014)

VSR Surgery

Acute MR

Acute mitral regurgitation secondary to papillary muscle

rupture is a life-threatening complication with a poor
prognosis

Usually diagnosed in 2 to 7 days post-AMI, the average

time is approximately 13 hours.

Papillary muscle rupture can be partially (occurring at

one end of the muscle) or complete.

Differential diagnosis of VSR distinguished by a site of

the murmur & by Swan-Ganz catheter

Pansystolic murmur loudest at the apex, with diastolic

components, and spread to the axilla.

ECG describe myocardial infarction posterior or inferior

Doppler Echocardiography is a standard for the

diagnosis, monitoring, and planning surgical therapy.

In an acute atmosphere, shock cardiogenic and

pulmonary edema may occur not enough time for
the LV to dilate or compensation

Management of Acute MR

Mitral valve repair & Mitral valve

replacement

LV Free Wall Rupture (LVFWR)

50% patients with LVFWR is diagnosed in 5 days post-AMI,

where 20% of them within 2 weeks.

Risk factors : age, female gender, HT, first AMI, & poor
collateral coronary artery

Blow-out ruptures are manifested with cardiogenic

shock (arterial pressure < 70 mmHg for at least 10
minutes)

ECG might manifest with increase of ST elevation by at

least 1mV in affected leads, ST elevation in aVL, noninversion of the T wave

Pericardial effusion is the most common

echocardiographic finding.

Doppler echocardiography may appear as a

discontinuity of the myocardium & bidirectional shunt

Management of LVFWR
(Hellenic Journal of Cardiology,
2002)

LVFWR Surgery

Management of Cardiogenic Shock in AMI

The aim of initial resuscitation is to stabilize oxygenation &

perfusion while revascularization is contemplated

We should prepare :

1.

DC shock

2.

Drugs : inotropes & vasopressors

3.

Reperfusion strategies : the trombolytic therapy,

percutaneous coronary intervention (PCI), surgical
(CABG)

4.

Mechanical circulatory support : IABP (Intraaortic Balloon

Pump Counterpulsation), extracorporeal membrane
oxygenation (ECMO), percutaneus Ventricular Assist
Devices/pVAD (Impella recover system, Tandem heart)

Algorism for the management of ischemic cardiogenic shock (Reynolds & Hochman, 2008)

IABP

ECMO

TandemHeart

Impella recovery system

Prognosis
VSR

Patients treated medically have poor overall prognosis,

with a mortality rate of 24% in 24 hours, 46% in 1 week,
and 82% mortality within 2 months.

Mortality after surgery is 42,9%.

54,1% mortality patient underwent surgery within 7 days

after MI higher than patients who underwent surgery at
more than 7 days (mortality rate 18,4%).

The highest mortality rate (> 60%) in patients who

underwent surgery in the first 24 hours

Acute MR

Only 25% patients survive acute MR 24 hours after the

rupture of papillary muscle.

The average survival of patients without surgery just three

days

In one study, 5126 patients who underwent surgical

intervention, the mortality rate was 26,9% with a 15-year
survival of 39%

LVFWR

Operative mortality of LVFWR between 12% to 30%.

Long-term outcome of these patients is the survival of 7

years.

Summary

The 3 most often mechanical complications after IMA

are ventricular septal rupture (VSR), acute mitral
regurgitation, and LV Free Wall Rupture (LVFWR)

This resulted in cardiogenic shock and require surgical

treatment.

The mortality rate of each complication is still high, after

surgery or without surgery.

Guideline Recommendation of Assist Devices According to ESC & AHA

Algorism for Revascularization in cardiogenic shock (ACC/AHA Guideline, 2003)

Definition of AMI (ESC 2012)

The term AMI should be used when there is evidence of

myocardial necrosis in a clinical setting consistent with
myocardial ischaemia.

Detection of rise and/or fall of cardiac biomarker values with

at least one of the following:
- Symptoms of ischaemia

- New or presumably new significant ST-T changes or new

LBBB
- Development of pathological Q waves in the ECG
- Imaging evidence of new loss of viable myocardium, or
new regional wall motion abnormality
- Identification of an intracoronary thrombus by angiography
or autopsy