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Copyright 2015 American Federation for Medical Research. Unauthorized reproduction of this article is prohibited.
Journal of Investigative Medicine Volume 63, Number 7, October 2015 Complications of Myocardial Infarction
Complications Types
Mechanical complications Cardiogenic shock, FWR, VSR, acute
MR, and true ventricular aneurysm
Electrical complications Bradyarrhythmias, tachyarrhythmia,
bundle branch blocks and
fascicular blocks
Inflammatory complications Peri-infraction pericarditis and
Dressler syndrome
Ischemic complications Postinfarction angina (infarct extension
and reinfarction)
FIGURE 2. Graph comparing survival after acute mechanical Embolic complications Mural thrombus and systemic embolism
complication of MI.3
Copyright 2015 American Federation for Medical Research. Unauthorized reproduction of this article is prohibited.
Bajaj et al Journal of Investigative Medicine Volume 63, Number 7, October 2015
channel blockers are best avoided in the early post-MI period until reason for no benefit of IABP may be inadequate hemodynamic
hemodynamic status is stabilized. The best evidence comes from support. Newer percutaneously inserted devices such as
the Clopidogrel and Metoprolol in Myocardial Infarction Trial/ Impella 2.5 (Abiomed) may provide superior hemodynamic
Second Chinese Cardiac Study 2 trial, which reported a 29% in- support compared with IABP.37 However so far, there is no strong
crease risk of death related to cardiogenic shock with the use of evidence to support their efficacy over IABP in AMI complicated
metoprolol in AMI, a particularly accentuated effect in high-risk by shock.38 As per recent AHA/ACC STEMI update, their use
patients.27 Inotropes and vasopressors should be used to maintain may be considered in patients with refractory shock.35
mean arterial pressure to prevent end organ damage. Dobutamine
and milrinone are the inotropes, and norepinephrine and dopamine
are the vasopressors commonly used in clinical practice. Dopamine FREE WALL RUPTURE
is an alpha and beta agonist with rapid escalation of alpha effect at The incidence of FWR was 2% to 6.2%3943 in the pre-
high doses, whereas norepinephrine is a predominantly alpha- perfusion era and it accounted for 15% of mortality after
adrenergic agent. In a subgroup analysis of a randomized trial, do- AMI41,42,44; however, the incidence has declined significantly in
pamine was associated with increased risk of mortality at 30 days the perfusion era. In a multinational Global Registry of Acute Cor-
compared with norepinephrine in cardiogenic shock.28 onary Events registry, one of the largest, the incidence of FWR
These pharmacological agents increase cardiac contractility was 0.2% with in-hospital mortality of 80%.3 In a study by
and blood pressure, but at the expense of increased myocardial ox- Moreno et al.,45 PCI independently reduces the risk of FWR in
ygen requirements. Still, their use is always required to maintain comparison with thrombolytic. The short-term mortality remains
perfusion of end organs. Dobutamine is recommended in predom- very high even with rapid diagnosis and timely surgery. Most of
inant left heart failure but its use best avoided in profound hypo- the ruptures occurred within the first 3 to 5 days but may happen
tension because of its vasodilating properties. The 2004 American up to 2 weeks.46 Some factors associated with FWR include the
College of Cardiology (ACC)/AHA guidelines for management following: age older than 55 years, female sex, no history of
of hypotension complicating AMI suggest the use of dobutamine previous MI, totally occluded left anterior descending (LAD),
as a first-line agent if systolic blood pressure ranges between 70 transmural MI, hypertension, Killip class greater than 2, persistent
and 100 mm Hg in the absence of signs and symptoms of shock.29 ST elevation, and use of corticosteroids and nonsteroidal inflam-
When response to dobutamine is inadequate or the patient's present- matory drugs (Table 2).3,39,47,48 Recognizing these factors early
ing systolic blood pressure is less than 70 mm Hg, the use of vaso- and carefully observing at-risk patients for early signs of cardiac
pressors, preferably norepinephrine, is suggested on the basis of rupture may help decrease the mortality. The relationship between
the recent data.28 Cardiogenic shock carries significant mortality the use of thrombolytics and the risk of rupture has been contro-
with 30-day mortality of approximately 40% and 1 year mortality versial.49,50 Many observational studies have reported an in-
of 51.5%.30,31 The overall in-hospital mortality has gone down creased risk of rupture with the use of thrombolytics.44,51 The
from 62.8% to 47.7% with the use of timely reperfusion Valsartan in Acute Myocardial Infarction trial reported an in-
therapy, as shown in Figure 4.11 creased use of thrombolytics in patients who died of FWR than
Many patients with profound cardiogenic shock do not re- other causes; however, it reduces the incidence of adverse out-
spond adequately to the previous measures and require mechani- comes.52 It was demonstrated by Honan et al.53 in a meta-
cal support to restore perfusion to vital organs and unload the analysis that timely thrombolytics reduces the risk of rupture
ventricle. An intra-aortic balloon pump (IABP) is one of the oldest and mortality, but the risk of rupture increases if thrombolytics
percutaneous mechanical support devices used in clinical practice. were administered beyond 14 hours of symptom onset. The
Previous studies, mostly observational, have shown improved out- mean time of FWR has decreased from 3 to 5 days in the
comes with IABP use.32,33 However, 2 recent randomized trials prethrombolytic era to 12 to 24 hours in the thrombolytic era.54
Counterpulsation Reduces Infarct Size Pre-PCI-Acute Myocar- Overall, it decreases mortality but mortality increases in the first
dial Infarction and IABP shockhave cast doubt on the efficacy 24 to 48 hours.54,55 On the contrary, PCI reduces the incidence
of IABP.30,31,34 Some authors have critiqued IABP shock, the of FWR and improves mortality and morbidity because of AMI.56
largest randomized trial till date, for low power because of lower There are 3 different types of cardiac rupture as follows:
than expected mortality, high crossover to IABP, and insertion of acute, subacute, and chronic.46 Among patients, 70% have acute
IABP after the PCI. However, on the basis of these trials, the FWR and they presented with sudden cardiac death and electro-
ACC/AHA recently downgraded the recommendation to use mechanical dissociation. In a few cases, the bleeding is stopped
IABP to IIA.35 Recent meta-analysis of 12 studies on the use of because of fibrin clot formation or pericardial adhere to the myo-
IABP in AMI did not show any mortality benefit.36 One potential cardium resulting in formation of pseudoaneurysm or chronic
FWR. Patients with chronic rupture either remain hemodynami-
cally stable or they can present with worsening shortness of breath
and arrhythmias. Sometimes, patient may have slow bleeding be-
cause of incomplete tear. The latter type of rupture is called sub-
acute rupture and emergent intervention can be lifesaving.
Clinical manifestation depends on rapidity of bleeding. Patients
may present with sudden cardiac death if bleeding is massive or
hypotension with cardiogenic shock if there is a slow progressive
bleeding.57,58 Patients may or may not have premonitory symp-
toms, but if present, they are persistent chest pain, agitation, and
recurrent emesis. Patients with subacute rupture almost always
present with hypotension. Sudden onset hypotension with brady-
cardia in a patient with AMI is highly suspicious for cardiac rup-
ture and should never be ignored. A patient may have persistent
FIGURE 4. Graph showing mortality in cardiogenic shock versus ST elevation or positive T-wave deflection that persists beyond
PCI trend.11 72 hours but is neither sensitive nor specific for subacute rupture.
Copyright 2015 American Federation for Medical Research. Unauthorized reproduction of this article is prohibited.
Journal of Investigative Medicine Volume 63, Number 7, October 2015 Complications of Myocardial Infarction
The accurate diagnosis of subacute FWR requires the presence within the first week and 62% to 82% within 2 months without
of high degree of suspicion.40 Echocardiogram typically shows surgical treatment.65,66 Even after surgery, there is 40% mortality.2
pericardial effusion, which can be present in up to 28% of patients It typically occurs 3 to 5 days after AMI and rarely after 2 weeks,
in a post-MI period in absence of cardiac rupture.59 The presence but there are case reports of VSR even after 30 days.63,67 With the
of echogenic masses increases both sensitivity (97%) and speci- advent of thrombolytic and PCI, VSRs occur earlier in patients
ficity (93%).59 According to Lopez-Sendon et al.,40 false positives with thrombolytic and PCI, and the mean time of onset of VSR
are very low if pericardial effusion is greater than 5 mm and has been reduced to 24 hours, probably because of intramyo-
pericardiocentesis should be performed before taking the patient cardial hemorrhage.18,67 The risk factors of VSR include hyper-
for surgery; clear pericardial fluid essentially rules out cardiac tension, old age, female, absence of angina, previous MI and
rupture. In a patient with hypotension, an echocardiogram sugges- extensive MI, and single vessel disease.18,63 More extensive in-
tive of pericardial effusion greater than 5 mm with intrapericardial farct leads to greater expansion and cavitary dilatation. Complete
echoes carries a sensitivity of 90.9% for cardiac rupture.40 The occlusion of an infarct-related artery also has been identified as a
presence of moderate to severe pericardial effusion (>10 mm) in risk factor.18,63 Septal rupture has been categorized morphologi-
patient with STEMI is associated with 43% of 30-day mortality; cally as simplea through-and-through defect at the same level
therefore, the presence of moderate pericardial effusion in patients and usually located anteriorlyor complexserpiginous dissec-
with recent MI should be considered secondary to FWR unless tion tract remote from the primary septal defect and usually lo-
proven otherwise.60 cated inferiorly. The ventricle septum is supplied by LAD in the
The treatment of subacute cardiac rupture is surgery. Medical upper two thirds and by the right coronary artery (RCA) in the
treatment aimed at stabilizing the patient acts as bridge to surgery lower one third in many cases when RCA is dominant and left cir-
and it includes intravenous fluids, inotropes, and small-volume cumflex when RCA is nondominant. In some cases, however, the
pericardiocentesis as guided by clinical status. The 30-day sur- LAD extends beyond the left ventricular apex, wrapping around to
vival is approximately 37%, according to the APEX-AMI trial.2 supply the distal inferior wall and inferior septum.
Hence, subacute cardiac rupture is a potentially treatable condition Patients with AMI due to occlusion of a wraparound LAD
with good long-term survival if recognized early and surgery is artery seem to have an elevated risk of septal rupture.68 Studies re-
performed in a timely manner. ported increased incidence of VSR with anterior-apical wall MI,
and LAD almost always is the culprit artery.18,63 However, when
it is associated with inferior wall MI, it is more complex and more
VENTRICULAR SEPTAL RUPTURE likely to have associated posterobasal aneurysm and right ventri-
The incidence of VSR in AMI was approximately 1% to 3% cle infarct and carries poor prognosis.65
before the reperfusion era6164; however, with the advent of reper- More than 50% of patients with VSR present with cardio-
fusion therapy, the incidence has decreased to 0.26%.3,6164 Ac- genic shock.18,68 Ventricular septal ruptures with inferior wall
cording to the APEX-AMI trial, its incidence is 0.17% in the MI are more likely to present with shock.68 Patients may present
PCI era.2 It accounts for 5% of all deaths in AMI.3 It carries a sig- with recurrent chest pain because of new onset of recurrent myo-
nificant mortality rate: approximately 46% of the patients die cardial necrosis, shortness of breath, decreased urine output, and
Copyright 2015 American Federation for Medical Research. Unauthorized reproduction of this article is prohibited.
Bajaj et al Journal of Investigative Medicine Volume 63, Number 7, October 2015
altered mentation secondary to decreased cardiac output. Typically, 25% and it could be due to missed defect or dehiscence of a patch
a new loud, harsh holosystolic murmur radiating to the axilla or extension of defect.76 Most of the shunts are well tolerated;
and apex is heard but associated with a thrill; murmur and thrill however, repeat surgery is performed in cases with severe ventric-
are less pronounced if the patient is in cardiogenic shock. In com- ular failure and it carries a mortality of 60%.77 Transcatheter clo-
parison to VSR, acute mitral regurgitation (MR) has a soft holo- sure of VSR is an alternative to surgery in an anatomically suitable
systolic murmur without a thrill. The patient may have bundle rupture and has shown promising results with both good short-
branch block because of disruption of conduction system pathway. term and long-term outcomes.78
Approximately 20% of patients who died of VSR also had associ-
ated FWR and PMR30; 10% to 20% of cases have coexistent se-
vere MR.64 Patients may have a big a and v wave because ACUTE MITRAL REGURGITATION
of increase RVEDP and increase pulmonary blood flow. Echocar- There are 2 main mechanisms of development of MR in AMI;
diogram with Doppler imaging is a highly sensitive and specific one is sudden rupture of the PMR and the second is ischemia-
technique and diagnostic in almost all cases. It also helps identify related papillary muscle wall dysfunction. Ischemic MR is much
other structural abnormalities that may be contributing to a decline more common than PMR. Prevalence of PMR after AMI is
in the patient's condition. Because of widespread availability of 0.26% in the PCI era.2 The prevalence of ischemic MR varies
echocardiograms, PAC is rarely used. A high pulmonary artery from 8% to 74%7984 if determined by Doppler echocardiogram
saturation (>80%) is suggestive of left to right shunt, and step and 1.6% to 9%8590 if determined by angiography. Such a wide
up of oxygen saturation in right ventricle rather than pulmonary range is because of variability in studies that estimated the preva-
artery differentiates it from severe MR. Left ventriculography lence of acute MR. The studies differ in terms of design, timing of
also may be used although it is rarely required to make a diagnosis imaging, severity of MR, and techniques used. Posteromedial rup-
of VSR. ture is more common than anterolateral rupture because of a dual
Medical therapy should be aimed at stabilizing the hemody- blood supply of the anterolateral muscle from LAD and left cir-
namics and acts as a bridge to surgery. It consists of respiratory cumflex and posteromedial muscle supplied only by posterior de-
support, mechanical support with the use of IABP, and afterload scending artery. Autopsy studies conducted on 22 patients with
reduction with the help of vasodilators. Inotropic support often PMR after AMI showed that 82% occurred in the first MI and
is needed in hypotensive patients. Surgery is almost always re- 50% had single vessel disease.91 It usually occurs 2 to 7 days after
quired in VSR. A recently published review of the Society of Tho- AMI and symptoms typically range from acute decompensated
racic Surgeons National Database (STS Database) identified 2876 heart failure to cardiogenic shock, leading to hypotension and
individuals aged 18 years or older who underwent post-MI VSR acute respiratory failure due to pulmonary edema. Varying de-
repair between 1999 and 2010.69 The overall operative mortality grees of systolic murmur can be heard, ranging from severe to
was 42.9%. Operative mortality was much lower for procedures no murmur. The systolic murmur can be holosystolic, mid or late.
considered elective (13.2% mortality) versus emergent (56.0% Murmur is not always heard because of concomitant left ventricu-
mortality) versus salvage (80.5% mortality).69 In the Global Utili- lar dysfunction leading to decrease in regurgitation jet volume and
zation of Streptokinase and Tissue Plasminogen Activator for rapid equalization of pressure in the ventricle and atria. Transtho-
Occluded Coronary Arteries-1 trial, there was 94% mortality at racic echocardiogram is the initial imaging modality of choice
30 days without surgery, suggesting that conservative manage- with a sensitivity of 65% to 85%; however, transesophageal echo-
ment is associated with very high mortality.63 There has been cardiogram may be required because of its higher diagnostic accu-
considerable debate in the past on the timing of surgery. Late sur- racy of 95% to 100%.92,93 Emergent or urgent surgery in the form
gery after 6 weeks was preferred more than early surgery, and of mitral valve repair or replacement is warranted; otherwise, 90%
studies reported longer survival.7072 Patients who underwent sur- of the patients die within the first week.94 There are no random-
gery within 7 days of presentation had a 54.1% mortality com- ized studies that compare repair and replacement or different re-
pared with 18.4% mortality if repair was delayed until after pair techniques for MR due to post-MI PMR.95 When PMR is
7 days.69 In a systematic review on postinfarction VSR done by complete, repair is not feasible because the tissue is very friable.
Papalexopoulou et al.,73 early surgery was recommended if VSR A segmental prolapse secondary to a partial PMR with limited
was greater than 15 mm with a significant shunt causing hemody- adjacent tissue damage is often amenable to a reliable repair.96,97
namic compromise; otherwise, surgery can be delayed up to 3 to In terms of medical management, patients should be stabilized
4 weeks in case of hemodynamically stable patient. Emergent sur- with oxygen, vasodilators, IABP, and inotropic support until sur-
gery should be performed if there is clinical deterioration.73 Mor- gery is arranged. Mitral valve surgery for PMR carries a very high
tality is highest in patients with basal septal rupture associated operative mortality; however, it has decreased in recent years
with inferior wall MI (70%, compared with 30% in patients with because of advances in surgical techniques and concomitant re-
anterior infarcts). The mortality rate is higher because of increased vascularization surgery. Long-term outcome of patients after sur-
technical difficulty and the frequent need for mitral valve repair or gery is really good, with a 5-year survival rate of 60% to
replacement in the patients with MR.18 Data about concomitant 70%.98,99 In a study by Russo et al.,99 long-term outcomes of pa-
revascularization along with septal repair are rather controversial; tients with PMR who survived PMR surgery have been similar to
however, revascularization reduces the ischemic burden, increases patients without PMR. Concomitant coronary revascularization
the collateral blood flow, and should be performed whenever in- should be performed because it is shown to improve short-term
dicated.70 Barker et al.74 reported that incomplete myocardial and long-term survival in these patients.96,99
revascularization is a significant predictor of late mortality after Ischemic MR is far more common than PMR and has short-
surgical repair of postinfarction VSR. In view of this, concomitant term and long-term prognostic significance. Patients with MR
CABG to all stenotic coronary arteries, including those supplying after AMI carry poor prognosis as compared with patients without
the noninfarcted area, is recommended for patients undergoing MR. In an analysis from the Controlled Abciximab and Device In-
surgical repair of VSR.75 A postoperative course is really crucial vestigation to Lower Late Angioplasty Complications trial of
in these patients for survival. Those who survive the initial event 1976 patients with STEMI, 10% had mild MR and 3% had mod-
and operation tend to have favorable 5- and 10-year outcomes. erate to severe MR. Patients with worse MR had significantly
Studies reported that incidence of recurrent shunt is approximately higher mortality rates at 30 days and at 1 year.90 The etiology of
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Journal of Investigative Medicine Volume 63, Number 7, October 2015 Complications of Myocardial Infarction
TABLE 3. American Heart Association Guidelines on Management of Mechanical Complications After AMI22,29,106
Cardiogenic shock
Class I
1. Emergency revascularization with either PCI or CABG is recommended in suitable patients with cardiogenic shock due to pump
failure after STEMI irrespective of the time delay from MI onset (level of evidence: B).
2. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI and cardiogenic shock
who are unsuitable candidates for either PCI or CABG (level of evidence: B).
3. Inotropic support (level of evidence: B).
4. Surgical correction of mechanical complications (level of evidence: B).
Class IIa
1. The use of IABP counterpulsation can be useful for patients with cardiogenic shock after STEMI who do not quickly
stabilize with pharmacological therapy (level of evidence: B).
Class IIb
1. Alternative LVassist devices for circulatory support may be considered in patients with refractory cardiogenic shock (level of evidence: C).
PMR
Class I
1. Patients with acute PMR should be considered for urgent cardiac surgical repair unless further support is considered futile because
of the patient's wishes or contraindications/unsuitability for further invasive care (level of evidence: B). Mitral valve replacement is
required in these patients.
2. Coronary artery bypass graft surgery should be undertaken at the same time as mitral valve surgery (level of evidence: B).
Ischemic MR
Class IIa
1. Mitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing
CABG or AVR (level of evidence: C).
Class IIb
1. Mitral valve repair or replacement may be considered for severely symptomatic patients (New York Heart Association class III-IV)
with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal Guideline Determined Medical Therapy
for heart failure (level of evidence: B).
2. Mitral valve repair may be considered for patients with chronic moderate secondary MR (stage B) who are undergoing other cardiac
surgery (level of evidence: C).
VSR
Class I
1. Patients with acute VSR should be considered for urgent cardiac surgical repair unless further support is considered futile because
of the patient's wishes or contraindications/unsuitability for further invasive care (level of evidence: B).
2. Coronary artery bypass graft surgery should be undertaken at the same time as mitral valve surgery (level of evidence: B).
FWR
Class I
1. Patients with FWR should be considered for urgent cardiac surgical repair unless further support is considered futile because of the
patient's wishes or contraindications/unsuitability for further invasive care (level of evidence: B).
2. Coronary artery bypass graft surgery should be undertaken at the same time as mitral valve surgery (level of evidence: C).
RVI
Class I
1. Patients with inferior STMI and hemodynamic compromise should be assessed with right-sided V4 lead to detect for ST elevation
and echocardiogram to screen for RVI (level of evidence: B).
2. The following principles apply to therapy with STEMI and RVI:
a. Early reperfusion should be achieved (level of evidence: C).
b. Atrioventricular synchrony should be achieved and bradycardia should be corrected (level of evidence: C).
c. Right ventricular preload should be optimized, which usually requires initial volume challenge in patients with hemodynamic
instability provided the jugular venous pressure is normal or low (level of evidence: C).
d. Right ventricular afterload should be optimized, which usually requires therapy for concomitant LV dysfunction (level of evidence: C).
e. Inotropic support should be used for hemodynamic instability not responding to volume challenge (level of evidence: C).
Class IIa
1. After infarction that leads to clinically significant right ventricular dysfunction, it is reasonable to delay CABG for 4 weeks to allow
time for recovery of contractile performance (level of evidence: C).
Corticosteroids and NSAID's use
Class III
1. Glucocorticoids and nonsteroidal anti-inflammatory drugs are potentially harmful for treatment of pericarditis after
STEMI (level of evidence: B).
Copyright 2015 American Federation for Medical Research. Unauthorized reproduction of this article is prohibited.
Bajaj et al Journal of Investigative Medicine Volume 63, Number 7, October 2015
ischemic MR had been long known because of papillary muscle PCI.108,115,116 Occlusion of RCA proximal to origin of right
dysfunction until Kaul et al.,100 Yiu et al.,101 and Levine et al.102 ventricular branch most commonly leads to right ventricular is-
demonstrated the pathophysiology of ischemic MR.100102 Ische- chemia, but many cases do not progress to infarction. The possible
mia causes displacement of apical and posterior papillary muscle explanations for this observation include the following: (1) thin
and wall motion abnormalities. This induces mitral valve tethering right ventricle muscle mass has less oxygen requirement and bi-
and causes systolic tenting of mitral valve leaflet away from the phasic blood supply during both systole and diastole as compared
annulus with incomplete closure of the valve. It is this alteration with LV; (2) diffusion of blood to the right ventricle through the
in the geometric relationship between ventricle and valve appara- right ventricle cavity; and (3) extensive collateral circulation from
tus that causes MR. It is more common in women, elderly, mul- left coronary system.117 Symptoms and signs of RVI are variable
tivessel disease, and previous MI.79,85,86 Medical management and range from asymptomatic patients to cardiogenic shock. The
plays a major role in treatment of ischemic MR, unlike PMR, classical clinical triad of hypotension, distended neck veins, and
where surgery is required. Prompt revascularization should be clear lung field in a setting of inferior wall MI has a very low
done if not already performed. Early revascularization has shown sensitivity for RVI, approximately 25%.118 An elevated jugular
to be effective in reducing MR and increases survival.103105 venous pressure and Kussmaul sign in the setting of inferior
Angiotensin-converting enzyme inhibitors and -blockers prevent wall MI carries very high sensitivity of 88% and specificity of
remodeling of LVand, hence, decrease ischemic MR. Aldosterone 100%.118 Electrocardiogram plays a very important role in mak-
antagonist should be used in addition to the previous therapy, if in ing diagnosis of RVI. In the setting of inferior wall MI, right-
heart failure and there are no contraindications. Diuretics often are sided leads should always be taken and ST elevation in V1 to
needed for volume overload. The role of mitral valve surgery is V6R confirms the diagnosis. Isolated ST elevation of 1 mm or
unclear in ischemic MR because of the absence of randomized more in V4R is enough to diagnose RVI.119,120 According to
control trials, but surgery in ischemic MR carries high mortality Robalino et al.,120 isolated ST elevation of 1 mm or more in
in comparison with surgery for structural MR. The AHA and V4R has sensitivity of 100% and specificity of 88% in diagnosing
the European Society of Cardiology recommendations for mitral RVI. Higher ST elevation in V4R as compared with other leads
valve surgery in ischemic MR are mentioned in Tables 3 and carries a bad prognosis with higher complications and in-hospital
4.106,107 The recurrence rate for MR is very high in these cases be- mortality.121 Two-dimensional echocardiogram is a noninvasive
cause of continuous left ventricular remodeling.108 The data and inexpensive imaging modality to assess the function of the
about type of surgery and repair versus replacement remain un- right ventricle; however, its close proximity to the sternum some-
clear. Previous studies and AHA guidelines favor repair more than times makes it difficult to fully assess the walls and function of
replacement; however, recent RCT in which repair was compared the right ventricle. Cardiovascular magnetic resonance imaging
with chordal sparing replacement showed no difference in out- using late gadolinium enhancement imaging enables the accurate
comes at 30 days and 1 year.109 The percutaneous mitral clip pro- characterization of ischemic myocardial injury. Studies have shown
cedure may be considered in patients with symptomatic severe that contrast-enhanced CMR is more sensitive for the detection of
secondary MR despite optimal medical therapy (including cardiac right ventricular involvement than physical examination, electrocar-
resynchronization therapy if indicated) if they fulfill the echo diography, and echocardiography in patients with an inferior MI.
criteria of eligibility, are considered high risk, and have a life ex- However, at the present time, we do not recommend its use,
pectancy greater than 1 year (recommendation class IIb, level of because it has not been shown to improve patient care in this set-
evidence: C).107 ting.109 Hemodynamic monitoring rarely is needed to make a di-
agnosis when echocardiogram is nondiagnostic. Disproportionate
elevation of right-sided pressure as compared with left-sided pres-
RIGHT VENTRICLE INFARCTION sure is the hallmark of RVI. Elevated right atrial pressure (RAP)
Right ventricle infarction is associated with approximately greater than 10 mm Hg and ratio of RAP/pulmonary artery pres-
50% of all cases of inferior wall MI.110,111 There is a variability sure greater than 0.8 suggest hemodynamically significant RVI.122
in reported incidence among the studies because of different diag- Therapy for patients with RVI is the same as for any other MI:
nostic methodologies used. The right ventricle has a complex dual antiplatelet therapy, statin, anticoagulants, and early reperfu-
shape and its evaluation can sometimes be challenging with sion therapy. Early revascularization improves right ventricular
2-dimensional echocardiography. According to late-enhancement function and decreases mortality and morbidity in RVI.123,124 In
cardiac magnetic resonance studies, the incidence of RVI is ap- a study by Assali et al.,125 complete revascularization of the right
proximately 45% to 57% in inferior wall MI and 11% to 65% in ventricular branch of RCA decreased 30-day mortality and signif-
anterior wall MI.109,112,113 Rarely, RVI presents as isolated MI icantly improved right ventricular function.125 Right ventricular
without inferior or anterior wall involvement, and it accounts for infarction is an independent predictor of mortality after inferior
3% of cases of STEMI.114 It usually occurs as a complication of wall MI and increases both hospital and 30-day mortality (shown
PCI of RCA; however, cases have been reported of isolated in Fig. 5); however, long-term outcomes of these patients are
RVI with occlusion of right ventricular branch of RCA without good.125,126 Early recognition of RVI is important to decrease
TABLE 4. European Society of Cardiology Guidelines for Mitral Valve Surgery in Chronic Ischemic Mitral Regurgitation107
Class I
1. Surgery is indicated in patients with severe MR undergoing CABG and LVEF > 30% (level of evidence: C).
Class IIa
1. Surgery should be considered in patients with moderate MR undergoing CABG (level of evidence: C).
2. Surgery should be considered in symptomatic patients with severe MR, LVEF < 30%, option for revascularization, and evidence of viability
(level of evidence: C).
Copyright 2015 American Federation for Medical Research. Unauthorized reproduction of this article is prohibited.
Journal of Investigative Medicine Volume 63, Number 7, October 2015 Complications of Myocardial Infarction
Copyright 2015 American Federation for Medical Research. Unauthorized reproduction of this article is prohibited.
Bajaj et al Journal of Investigative Medicine Volume 63, Number 7, October 2015
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