Echo in Emergencies

Mechanical Complications
of Acute Myocardial Infarction
M. Joo Andrade, Lisbon PT

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Complications of Acute MI
Free wall rupture and pseudoaneurysm

Ventricular septal rupture

Acute MR (papillary muscle displacement or rupture)
RV infarction

Infarct expansion, aneurysm, LV remodeling

Thrombus

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Cardiac Rupture
The wavefront of cell death

Transmural
AMI

LV free
wall

IVS

Papillary
muscle

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Cardiac Rupture
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

50% < 5 days

>90% within 15 days

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)

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Mechanical complications after PCI in STEMI

APEX-AMI
Survival after mechanical complication
Proportion surviving

No mechanical complication

73%

52 of 5,745 pts

Acute mitral regurgitation

15 (0,26%)

(0,91%)

23,5 h after symptoms onset

37%
Free wall rupture
30 (0,52%) 20%
Ventricular septal rupture
10 (0,17%)

Days post-complication or post-randomization

French JK et al. Am J Cardiol 2010; 105:59-63
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Free-wall Rupture - Presentation

Acute blowout form
Rapid 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 cases

Ventricular perforation sealed by organized thrombus and the pericardium

May 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
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Subacute free wall rupture

69 y-old man
late reperfused inferior MI

Raposo L, Andrade MJ et al
Cardiovascular Ultrasound 2006, 4:46

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Subacute free wall rupture

Surgical Findings
Inferior wall MI with rupture
Haematic pericardial effusion
with thrombi /blood cloths
Impending tamponade
Raposo L, Andrade MJ et al
Cardiovascular Ultrasound 2006, 4:46

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

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
Cardiovascular Ultrasound 2009, 7:36

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

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

Gomes R, Andrade MJ et al
Cardiovascular Ultrasound 2009, 7:36

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Acute MR and IVS rupture

Incidence
Pre-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 Profile
Demographics: advanced age and female
Past history: hypertension
MI location: Acute MR inferior; IVS Rupture anterior

Timing
Old 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)
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

IVS Rupture Pathophysiology

Location
Apical: anterior MI
Multiple: 40%

Basal: inferior MI
Direct/simple VS Serpiginous/Complex

Associated CAD
Multivessel 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

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Acute MR Pathophysiology
Location
Postero-medial papillary muscle (PD): 75%
Antero-lateral papillary muscle (LAD + LCX): 25%
Partial (2/3) >> Complete rupture (1/3)
Small infarcts: 50%

Associated CAD
Multivessel disease: 40%

Magnitude of Mitral Regurgitation

Determined by the extent of papillary muscle rupture
Determines the extent of haemodynamic compromise

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Acute MR and IVS rupture

Clinical Presentation
Acute
Pulmonary
Oedema

Cardiogenic
Shock

Physical Examination
Systolic murmur
Thrill

Acute MR

IVS rupture

50%
no

90%
50%

The degree of haemodynamic instability

The most important predictor of outcome
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Acute MR and IVS rupture

Diagnosis and management PA Catheter
50
40

Acute MR

30
20
10

75

RA O2 Sat = 71%

PA O2 Sat = 93%

60

IVS Rupture

45
30
15

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Ventricular Septal Rupture - TTE

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Ventricular Septal Rupture - TTE

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Ventricular Septal Rupture TTE

Doppler measurements

LV/RV Peak grad

QP:QS

E/E=18

RV/RA Peak grad

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

IVS Rupture TEE

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

IVS Rupture Intra-operative TEE

Courtesy of J Almeida, Oporto

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Papillary Muscle Rupture - TEE

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Mitral regurgitation - TTE

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Papillary Muscle Rupture - TTE

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

After mitral valve replacement

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Management Medical Treatment

Acute MR and IVS Rupture

while emergency surgery is being arranged

Goals

magnitude regurgitation/shunt
systemic perfusion
ventricular performance
Vasodilators: Nitroprusside, nitroglycerin
Inotropic agents: Dobutamine
Intra-aortic balloon counterpulsation

Mechanical ventilation
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Ischaemic mitral regurgitation

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

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Mitral Regurgitation after AMI portends an adverse

prognosis with increased risk of death

Francesca Bursi et al. Circulation 2005; 111:295-301

Feinberg M et al. Am J Cardiol 2000; 86:903-907

Mild Mitral Regurgitation after MI is a significant

predictor for 1-year all-cause mortality

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Indications for surgery in ischaemic MR

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Left ventricular aneurysm

Incidence (8-15%)
Differential diagnosis (pseudoaneurysm)

Complications
HF, sustained VT, arterial embolism
Treatment
indications for surgical repair
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Left ventricular aneurysm

Surgical repair

Courtesy of J Almeida, Oporto

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Left ventricular thrombus

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

RV infarction

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

LV Remodeling after AMI

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

Predictors of LV Remodeling after AMI

Pre-existing hypertension
Infarct size
Cardiac enzyme index
Anterior location
Transmurality of infarction

Large asynergic zone (high WMSi)

Ejection Fraction
Infarct expansion

Mostly

End-systolic volume
Patency of the IRA
Microvascular obstruction

Short early mitral DT

TIMI grade <3 flow

Mitral regurgitation
Viability

Left atrial enlargement

Markers of neurohormonal activation

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

interrelated
risk factors

LV Dyssynchrony acutely after MI

predicts LV remodeling

No dyssynchrony at baseline

Dyssynchrony at baseline

No remodeling at follow-up

Remodeling at follow-up

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

EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

TT Coronary Flow Reserve after Successful P-PTCA

for Acute anterior MI is an Independent Predictor
of LV Recovery and in-hospital CE
Doppler echocardiographic parameters

r=0.63
P<0.0001

best cutoff for CFR = 1.7

Sensitivity = 76%
Specificity = 96%
AUC, 0.87; P < .01
Meimoun P et al. J Am Soc Echocardiogr 2009;22:1071-9
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

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
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010