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Mechanical Complication of Acute Myocardial Infarction Secondary to COVID-19 Disease

  • Author Footnotes
    1 Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA
    ,
    Author Footnotes
    2 Johns Hopkins University School of Medicine, Baltimore, MD Medical College of Georgia, Augusta, GA Northside Hospital Cardiovascular Institute, Atlanta GA
    Abdulla A. Damluji
    Correspondence
    CORRESPONDING AUTHOR (no reprints will be ordered): Abdulla A. Damluji, MD, PhD Associate Professor of Medicine (Cardiology) Johns Hopkins University School of Medicine Inova Center of Outcomes Research 3300 Gallows Road, Falls Church, VA 22042
    Footnotes
    1 Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA
    2 Johns Hopkins University School of Medicine, Baltimore, MD Medical College of Georgia, Augusta, GA Northside Hospital Cardiovascular Institute, Atlanta GA
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  • Nikhil R. Gangasani
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  • Author Footnotes
    1 Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA
    2 Johns Hopkins University School of Medicine, Baltimore, MD Medical College of Georgia, Augusta, GA Northside Hospital Cardiovascular Institute, Atlanta GA

      INTRODUCTION

      The aggressive inflammatory response to COVID-19 can result in airway damage, respiratory failure, cardiac injury, and multiorgan failure, which lead to death in susceptible patients.
      • Fauci A.S.
      • Lane H.C.
      • Redfield R.R.
      Covid-19 - Navigating the Uncharted.
      ,
      • Damluji A.A.
      • Wei S.
      • Bruce S.A.
      • et al.
      Seropositivity of COVID-19 among asymptomatic healthcare workers: A multi-site prospective cohort study from Northern Virginia, United States.
      Cardiac injury and acute myocardial infarction (AMI) secondary to COVID-19 disease can lead to hospitalization, heart failure, and sudden cardiac death.
      • Rosner C.M.
      • Genovese L.
      • Tehrani B.N.
      • et al.
      Myocarditis Temporally Associated With COVID-19 Vaccination.
      When serious collateral damage from tissue necrosis or bleeding occurs, mechanical complications of myocardial infarction and cardiogenic shock can ensue. While prompt reperfusion therapies have decreased the incidence of these serious complications, patients who present late following the initial infarct are at increased for mechanical complications, cardiogenic shock, and death. The health outcomes for patients with mechanical complications are dismal if not recognized and treated promptly.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Even if they survive serious pump failure, their CICU stay is often prolonged, and their index hospitalization and follow-up visits may consume significant resources and impact the healthcare system.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      After the spread of the COVID-19 in the United States and the world, an increase in the incidence of mechanical complications of AMI was observed, likely because of delayed presentation in patients without COVID.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      • Albiero R.
      • Seresini G.
      Subacute Left Ventricular Free Wall Rupture after Delayed STEMI Presentation During the COVID-19 Pandemic.
      • Moroni F.
      • Gramegna M.
      • Ajello S.
      • Beneduce A.
      • Baldetti L.
      • Vilca L.M.
      • Cappelletti A.
      • Scandroglio A.M.
      • Azzalini L.
      Collateral Damage: Medical Care Avoidance Behavior Among Patients With Myocardial Infarction During the COVID-19 Pandemic.
      • Damluji A.A.
      • van Diepen S.
      • Katz J.N.
      • et al.
      Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association.
      • O'Gara P.T.
      • Kushner F.G.
      • Ascheim D.D.
      • et al.
      ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
      Cardiologists, cardiac intensivist, and surgeons are faced with the challenges of managing mechanical complications and the associated discussion on appropriate therapies often occurs among heart teams in specialized shock centers. Prompt recognition of clinical signs and symptoms of acute pump failure is needed to avoid prolonged states of shock, advanced forms of heart failure, and death. Differentiation between mechanical complications of type I and type II AMI secondary to COVID-19 infection requires clinical bedside knowledge, utilization of non-invasive imaging, and invasive hemodynamic assessment. Even if the diagnosis is made promptly, the management of these patients is often complex and requires the expertise of a multidisciplinary teams. Because post-MI mechanical defects are rare, the management is variable depending on the expertise of each cardiac center caring for these patients. This chapter aims to address the most common mechanical complications encountered after COVID-19 disease; (2) define a multidisciplinary approach to management; and (3) highlight a case series discussing management strategies in practice.

       VENTRICULAR SEPTAL DEFECT

      Before thrombolysis and primary revascularization became the standard of care, the incidence of ventricular septal defects (VSD) caused by transmural myocardial infarct rupture was approximately 1-2%, compared to under 0.3% in contemporary practice.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Risk factors include older age, female sex, and delayed reperfusion.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Typically occurring three to five days post-infarction, presentations range from incidental findings to circulatory collapse. Symptoms may include recurrent chest pain, dyspnea, and orthopnea. Clinical examination may reveal a systolic murmur, rales, hypotension, cool skin, with signs of pulmonary venous congestion.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      A 12-lead electrocardiogram may identify progressive ischemia and associated arrythmias.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Echocardiography is diagnostic, evaluating size and location of a left-to-right shunt (Fig 2), biventricular function, presence of LV thrombus, mitral regurgitation, pulmonary artery and right-sided pressures, free-wall rupture and tamponade.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Right heart catheterization shows a diagnostic step-up in oxygenation between the right atrium and pulmonary artery and elevated pulmonary-to-systemic flow ratio (up to 8:1 depending on the ventricular septal defect (VSD) size.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Left heart catheterization commonly shows a complete coronary obstruction without collateral circulation and left ventriculography shows contrast in the right ventricle and pulmonary artery.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Anterior and apical ischemic VSDs are caused by infarcts in the left anterior descending (LAD) territory and posterior VSDs are due to inferior infarcts.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Right ventricular infarction or ischemia with severe dysfunction is an important feature of VSDs caused by acute, proximal right coronary occlusion.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Posterior VSDs are often accompanied by mitral valve regurgitation commonly secondary to ischemic remodeling.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Figure thumbnail gr1
      Figure 1Arrow shows inferior apical ventricular septal defect
      Figure thumbnail gr2
      Figure 2Ventricular septal defect with left-to-right shunting
      Because of the 80% 30-day mortality associated with uncorrected defects, medical therapy alone is limited to hemodynamically insignificant defects, or prohibitive risk patients.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Effective afterload reduction to decrease the left-to-right shunt is essential: intra-aortic balloon pumps or impella with pharmacotherapy are used in over 80% of emergencies and 65% of urgent repairs. Temporary percutaneous ventricular assist devices are increasingly employed.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Patients severely compromised by multi-organ failure may benefit from biventricular mechanical support or extra-corporal membrane oxygenation with percutaneous or surgical left ventricular vents, allowing end-organ recovery before definitive surgery.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Emergency surgery is indicated for cardiogenic shock with pulmonary edema refractory to mechanical circulatory support. Lower mortality is reported when surgery is delayed for a week after diagnosis, although selection and survival bias may explain this.
      Coronary bypasses are performed first, commonly with saphenous veins, to facilitate myocardial protection and minimize handling the heart after VSD repair. Primary repair (Dagett) or infarct exclusion (David) techniques are used.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      For anterior VSDs the infarcted surface of the anterolateral left ventricle (LV) is incised parallel to the LAD.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      The defect in the septum is usually immediately beneath the incision. A patch repair using pericardium is performed using mattress sutures with the pledgets on the right ventricular side in non-infarcted myocardium, so the whole LV aspect of the septum is excluded from the mitral anulus to the anterolateral LV wall.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      It is usually possible to close the left ventriculotomy primarily with mattress sutures buttressed with pericardium or felt, reinforced with continuous sutures and bioglue. True apical VSDs can be repaired and closed primarily by amputating the apex.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Posterior VSDs are approached via a ventriculotomy in the infarcted posterior LV wall parallel to the posterior descending coronary artery, attaching a patch to the LV aspect of the non-infarcted septum with patch closure, primary closure or infarct exclusion depending on how much free ventricular wall is infarcted.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Temporary left ventricular assist devices decompress the LV reducing risk of left ventriculotomy rupture and supporting cardiac output post-operatively. The 40% peri-operative mortality has not changed significantly in decades.
      • Fauci A.S.
      • Lane H.C.
      • Redfield R.R.
      Covid-19 - Navigating the Uncharted.
      ,
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      There have been case reports and small series of percutaneous VSD closure using PFO closure devices, with variable outcomes.

       VSD Case

      A 50-year-old Hispanic male developed chest pain radiating to the back >72 hours prior to admission. He reported a similar self-limiting episode a week prior. He presented to the hospital where he was found to be in Killip class 4 heart failure and inferior MI. His initial heart rate was 123 BPM, BP 74/56. He was COVID negative. Emergent cardiac catheterization revealed 3 vessel coronary disease with 100% occlusion of the right coronary (Fig 3) and LAD with no collaterals. Placement of 4 stents in the mid and distal right coronary failed to restore flow and remained TIMI 0. Echocardiography performed during catheterization showed EF > 70% and inferior apical VSD (Figure 1). The patient was ultimately maintained on an intra-aortic balloon pump and transferred to a quaternary care facility where he underwent surgical repair, had impella and ECMO placed but ultimately expired.
      Figure thumbnail gr3
      Figure 3Coronary angiogram demonstrating 100% occlusion of right coronary artery
      Case 2
      A 74-year-old Caucasian female developed chest pain after receiving her COVID shot 1 week prior to admission but did not seek medical attention. She later presented to the hospital where she was found to be in Killip class 4 heart failure and ECG showing anterior MI. Her initial heart rate was 122 BPM, BP 103/73. She was COVID negative. Emergent cardiac catheterization demonstrated 2 vessel coronary disease with 100% occlusion of the proximal left anterior descending (Fig 6) with no collaterals. She underwent placement of a stent that restored TIMI-3 flow. After catheterization, left ventriculography showed presence of a ventricular septal defect (Figure 4). EF was estimated at 15-20%. The patient was ultimately maintained on an intra-aortic balloon pump and transferred to a quaternary care facility. She underwent VSD repair 10 days later but decompensated and died 3 weeks after initial hospital presentation despite support with ECMO and renal replacement therapy.
      Figure thumbnail gr4
      Figure 4Left ventriculography shows contrast in both left and right ventricles, demonstrating ventricular septal defect
      Figure thumbnail gr5
      Figure 5Arrow indicates ventricular septal defect on left ventriculography
      Figure thumbnail gr6
      Figure 6Occlusion of proximal left anterior descending artery

       PAPILLARY MUSCLE RUPTURE

      The incidence of acute severe mitral regurgitation (Fig 8) from papillary muscle rupture (PMR), like other mechanical complications of acute MI (AMI), has declined in the reperfusion era to less than 0.05%.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Primary PCI has further reduced the incidence compared to thrombolysis. Despite this decline, excess hospital mortality is reported compared to AMI patients without PMR (36.3% vs. 5.3%) in the current era.
      • Fauci A.S.
      • Lane H.C.
      • Redfield R.R.
      Covid-19 - Navigating the Uncharted.
      Figure thumbnail gr7
      Figure 7Evidence of ruptured posterior papillary muscle on echocardiography
      Figure thumbnail gr8
      Figure 8Eccentric mitral regurgitation jet due to papillary muscle rupture
      PMR occurs most frequently after inferior AMI in patients with no history of prior CAD. It is more common with STEMI than NSTEMI. The posteromedial papillary muscle is more often involved because of its single blood supply.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      PMR may be complete or partial, which may affect the ease of diagnosis and severity of clinical symptoms.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Risk factors for PMR include older age, lack of revascularization after AMI, and delay in presentation after AMI.
      • Damluji A.A.
      • Wei S.
      • Bruce S.A.
      • et al.
      Seropositivity of COVID-19 among asymptomatic healthcare workers: A multi-site prospective cohort study from Northern Virginia, United States.
      PMR typically occurs within 7 days of AMI.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Patients present with pulmonary edema and may quickly progress to cardiogenic shock (CS). A murmur may be absent due to equalization of left atrial and left ventricular pressures. Transthoracic echocardiography may not be diagnostic, particularly in cases of partial PMR. Transesophageal echocardiography or angiographic left ventriculography (Fig 5) has a high diagnostic sensitivity.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Left ventricular ejection fraction is often normal or low-normal. Coronary angiography will most often demonstrate single or 2-vessel CAD, with total occlusion of the infarct-related artery.
      Patients may require mechanical ventilation. A pulmonary artery catheter is useful for titration of vasoactive medications. Patients that do not present with CS commonly experience rapid deterioration of their hemodynamics. An intra-aortic balloon pump may be beneficial for patients with CS and the experience with mechanical circulatory support, including percutaneous VADs and VA-ECMO for stabilization in PMR is limited. Emergent mitral valve surgery is the standard treatment, and it should occur within hours of diagnosis. For patients that are hemodynamically stable on support, the urgency of mitral valve surgery may be diminished.
      Patients included in surgical series of PMR treatment are highly selected and their outcomes cannot be generalized to all-comers.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Many patients with PMR are not offered surgery. In the SHOCK trial registry, only 38% of patients with CS from acute severe MR after AMI were offered mitral valve surgery.
      • Rosner C.M.
      • Genovese L.
      • Tehrani B.N.
      • et al.
      Myocarditis Temporally Associated With COVID-19 Vaccination.
      A recent analysis of AMI admissions from the National Inpatient Sample found that only 58% of patients with PMR underwent mitral valve surgery.
      • Fauci A.S.
      • Lane H.C.
      • Redfield R.R.
      Covid-19 - Navigating the Uncharted.
      Factors that may influence this decision include advanced age, comorbidities, and inability to stabilize the patient while awaiting surgery.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Chordal-sparing mitral valve replacement is generally preferred over repair because the operation is predictable and its durability established. Small series have reported repair techniques, typically for patients with partial PMR and less preoperative hemodynamic derangement.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Concomitant CABG should be considered in patients with PMR and severe CAD. The surgeon must weigh the risks and benefits of prolonging the operation with CABG. Some surgical series have reported improved outcomes with concomitant CABG. Recently there have been reports of using percutaneous mitral clip repairs with reasonable results.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.

       Papillary Muscle Rupture Case

      A 60-year-old Caucasian male developed chest pain >72 hours prior to admission. Due to progressive dyspnea, he presented to the hospital where he was found to be in Killip class 3 heart failure. His initial heart rate was 116 BPM, BP 90/62 mmHg, pulmonary rales and systolic murmur were noted. He was COVID negative. Emergent cardiac catheterization demonstrated 3 vessel coronary disease with 100% occlusion of the circumflex with no collaterals. He underwent placement of 4 stents in the circumflex, second obtuse marginal branch and left main coronary with restoration of TIMI 3 flow. After catheterization, echocardiography showed EF 35-40% with posterior papillary muscle rupture (Figure 7). The patient was scheduled for surgical mitral valve repair but developed sudden cardiogenic shock and died 4 days after hospital presentation.

       FREE WALL RUPTURE

      Although free wall rupture (FWR) is the most common mechanical complication following acute myocardial infarction, its true incidence is unknown because of out of hospital sudden cardiac death and lack of routine autopsy.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      While the overall incidence of rupture has undoubtedly decreased with prompt acute reperfusion therapy for STEMI, the early hazard noted at 24 hours in thrombolytic versus placebo trials established the risk of FWR with delayed reperfusion therapy.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Honda S.
      • Asaumi Y.
      • Yamane T.
      • et al.
      Trends in the clinical and pathological characteristics of cardiac rupture in patients with acute myocardial infarction over 35 years.
      This phenomenon is attributed to intra-myocardial hemorrhage, myocardial dissection, and subsequent rupture: a phenomenon that has also been noted following primary percutaneous intervention.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Formica F.
      • Mariani S.
      • Singh G.
      • et al.
      Postinfarction left ventricular free wall rupture: a 17-year single-centre experience.
      Free wall rupture should be suspected in any patient with hemodynamic instability or collapse following an AMI, especially in the setting of delayed, ineffective or absent reperfusion therapy.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      The clinical exam classically shows jugular venous distension, a pulsus-paradoxus or frank electromechanical disassociation and muffled heart sounds in the setting of cardiovascular collapse.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      It is sometimes preceded by chest pain and nausea, and EKG may show new ST elevation as contact with blood irritates the pericardium. Instant death is common in a blowout rupture, but in exceptional cases, a prompt bedside echocardiogram confirms the diagnosis and warrants emergent surgical correction. A variant of frank rupture characterized by a mushy infarct zone with an oozing bloody pericardial effusion should be recognized.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      In cases of circulatory collapse, immediate placement on ECMO support may provide an opportunity to stabilize the circulation and perform definitive repair with acceptable results.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • FitzGibbon G.M.
      • Hooper G.D.
      • Heggtveit H.A.
      Successful surgical treatment of postinfarction external cardiac rupture.
      The initial surgical repair was performed by Fitzgibbons and involved an infarctectomy with defect closure on cardiopulmonary bypass.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Matteucci M.
      • Fina D.
      • Jiritano F.
      • et al.
      Treatment strategies for post-infarction left ventricular free-wall rupture.
      The goals of surgical intervention revolve around repairing the defect, treating tamponade, and leaving behind adequate healthy tissue that will minimize late complications.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Damluji A.A.
      • Forman D.E.
      • van Diepen S.
      • et al.
      Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association.
      The preferred technique utilized is guided by anatomy and presentation, and may rarely be limited to a linear closure, but often involves an infarctectomy when extensive necrosis is present with patch closure with materials like Dacron or pericardium. The ideal repair when anatomy allows is a primary patch repair that covers the defect but when feasible a sutureless repair utilizing a patch and glue or a collagen sponge patch can be performed with or without the need for ongoing cardiopulmonary bypass. A percutaneous approach utilizing intra pericardial fibrin-glue injection is evolving.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.

       PSEUDOANEURYSM

      Pseudoaneurysms of the left ventricle develop when cardiac rupture is contained by pericardial adhesions.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Dudiy Y.
      • Jelnin V.
      • Einhorn B.N.
      • Kronzon I.
      • Cohen H.A.
      • Ruiz C.E.
      Percutaneous closure of left ventricular pseudoaneurysm.
      • Inayat F.
      • Ghani A.R.
      • Riaz I.
      • et al.
      Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management.
      • Mackenzie J.W.
      • Lemole G.M.
      Pseudoaneurysm of the left ventricle.
      • Yeo T.C.
      • Malouf J.F.
      • Oh J.K.
      • Seward J.B.
      Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm.
      • Prifti E.
      • Bonacchi M.
      • Baboci A.
      • et al.
      Surgical treatment of post-infarction left ventricular pseudoaneurysm: Case series highlighting various surgical strategies.
      Although they may occur following cardiovascular surgery, blunt or penetrating chest trauma, or as a result of infective endocarditis, they are most commonly associated with prior acute myocardial infarction.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Inayat F.
      • Ghani A.R.
      • Riaz I.
      • et al.
      Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management.
      • Mackenzie J.W.
      • Lemole G.M.
      Pseudoaneurysm of the left ventricle.
      • Yeo T.C.
      • Malouf J.F.
      • Oh J.K.
      • Seward J.B.
      Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm.
      • Prifti E.
      • Bonacchi M.
      • Baboci A.
      • et al.
      Surgical treatment of post-infarction left ventricular pseudoaneurysm: Case series highlighting various surgical strategies.
      Compared to true aneurysms, pseudoaneurysms more often involve the posterior or lateral wall – perhaps the result of dependent pericardial adhesions developing in the recumbent, convalescing post-infarction patient.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      While acute anterior wall rupture is thought to result in unrelenting hemopericardium, catastrophic tamponade, and immediate death, other pseudoaneurysms can remain undiagnosed for several months or longer.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Inayat F.
      • Ghani A.R.
      • Riaz I.
      • et al.
      Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management.
      • Mackenzie J.W.
      • Lemole G.M.
      Pseudoaneurysm of the left ventricle.
      • Yeo T.C.
      • Malouf J.F.
      • Oh J.K.
      • Seward J.B.
      Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm.
      • Prifti E.
      • Bonacchi M.
      • Baboci A.
      • et al.
      Surgical treatment of post-infarction left ventricular pseudoaneurysm: Case series highlighting various surgical strategies.
      Patients with pseudoaneurysm may present with a myriad of signs or symptoms, none of which can be considered pathognomonic for the condition. While previous case series have argued that nearly half of afflicted individuals will be asymptomatic at the time of diagnosis
      • Prifti E.
      • Bonacchi M.
      • Baboci A.
      • et al.
      Surgical treatment of post-infarction left ventricular pseudoaneurysm: Case series highlighting various surgical strategies.
      , more contemporary studies and systematic reviews instead note that the majority will be expected to present with congestive heart failure, chest pain, or shortness of breath. Others may develop symptomatic arrhythmias, signs of systemic embolization, and even sudden cardiac death. Most patients are male, and will have both electrocardiographic (e.g. ST segment changes) and radiographic (e.g. “mass-like” protuberance on plain film or cardiomegaly) abnormalities at presentation.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      ,
      • Dudiy Y.
      • Jelnin V.
      • Einhorn B.N.
      • Kronzon I.
      • Cohen H.A.
      • Ruiz C.E.
      Percutaneous closure of left ventricular pseudoaneurysm.
      Diagnosis requires a high index of suspicion, and often necessitates the use of multiple complimentary imaging tools; among these include coronary angiography and ventriculography, two-dimensional transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography, and magnetic resonance imaging.
      • FitzGibbon G.M.
      • Hooper G.D.
      • Heggtveit H.A.
      Successful surgical treatment of postinfarction external cardiac rupture.
      • Matteucci M.
      • Fina D.
      • Jiritano F.
      • et al.
      Treatment strategies for post-infarction left ventricular free-wall rupture.
      • Damluji A.A.
      • Forman D.E.
      • van Diepen S.
      • et al.
      Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association.
      • Dudiy Y.
      • Jelnin V.
      • Einhorn B.N.
      • Kronzon I.
      • Cohen H.A.
      • Ruiz C.E.
      Percutaneous closure of left ventricular pseudoaneurysm.
      • Inayat F.
      • Ghani A.R.
      • Riaz I.
      • et al.
      Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management.
      Pseudoaneurysms will usually have a narrow neck and, as noted above, will lack the normal structural elements found in an intact cardiac wall.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
      Left ventricular pseudoaneurysms are felt to represent surgical emergencies due to their high risk for progressive rupture. In truth, however, little is known about the natural history of medically managed disease. In one small series of patients at the Mayo Clinic, none of those treated conservatively (without operative intervention) succumbed to fatal hemorrhage. Instead, the majority died as a result of other complications, including recurrent ischemia or progressive heart failure.
      • Dudiy Y.
      • Jelnin V.
      • Einhorn B.N.
      • Kronzon I.
      • Cohen H.A.
      • Ruiz C.E.
      Percutaneous closure of left ventricular pseudoaneurysm.
      It is important to acknowledge that the contemporary literature is quite sparse, and likely undermined by selection and publication bias. While case reports of percutaneous repair exist
      • Inayat F.
      • Ghani A.R.
      • Riaz I.
      • et al.
      Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management.
      , most experts still believe that immediate surgical management is prudent. Surgeons should be prepared to quickly institute cardiopulmonary bypass at the time of operative intervention, as rupture and hemodynamic collapse can occur soon after pericardial manipulation.
      • Alsidawi S.
      • Campbell A.
      • Tamene A.
      • et al.
      Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.

      CONCLUSION

      COVID-19 disease resulted in a substantial increase in the incidence of myocardial injury, heart failure and death. In addition, stay-at-home mandates and patient fear of contracting COVID at the hospital has the unintended consequence of fewer STEMI patients being treated. In severe cases, mechanical complication of AMI can occur particularly among those with delayed presentation after initial cardiac injury. Without a prompt and systematic approach to management, the outcomes for patients with mechanical complications are poor. The management involves a high level of suspicion particularly among patients with hemodynamic compromise. The utilization of “Heart Team” facilitates a systematic approach to management and ensures a discussion to all therapeutic options to provide hemodynamic stability and durable outcomes.
      Clinics Care Points

      REFERENCES

        • Fauci A.S.
        • Lane H.C.
        • Redfield R.R.
        Covid-19 - Navigating the Uncharted.
        N Engl J Med. 2020; 382: 1268-1269
        • Damluji A.A.
        • Wei S.
        • Bruce S.A.
        • et al.
        Seropositivity of COVID-19 among asymptomatic healthcare workers: A multi-site prospective cohort study from Northern Virginia, United States.
        Lancet Reg Health Am. 2021; 2: 100030
        • Rosner C.M.
        • Genovese L.
        • Tehrani B.N.
        • et al.
        Myocarditis Temporally Associated With COVID-19 Vaccination.
        Circulation. 2021; 144: 502-505
        • Alsidawi S.
        • Campbell A.
        • Tamene A.
        • et al.
        Ventricular Septal Rupture Complicating Delayed Acute Myocardial Infarction Presentation During the COVID-19 Pandemic.
        JACC Case Rep. 2020 Aug; 2 (Epub 2020 Jun 12. PMID: 32835258; PMCID: PMC7290201): 1595-1598https://doi.org/10.1016/j.jaccas.2020.05.049
        • Albiero R.
        • Seresini G.
        Subacute Left Ventricular Free Wall Rupture after Delayed STEMI Presentation During the COVID-19 Pandemic.
        JACC Case Rep. 2020 Aug; 2 (Epub 2020 Jul 8. PMID: 32835259; PMCID: PMC7342086): 1603-1609https://doi.org/10.1016/j.jaccas.2020.06.040
        • Moroni F.
        • Gramegna M.
        • Ajello S.
        • Beneduce A.
        • Baldetti L.
        • Vilca L.M.
        • Cappelletti A.
        • Scandroglio A.M.
        • Azzalini L.
        Collateral Damage: Medical Care Avoidance Behavior Among Patients With Myocardial Infarction During the COVID-19 Pandemic.
        JACC Case Rep. 2020 Aug; 2 (Epub 2020 Apr 23. PMID: 32835261; PMCID: PMC7252183): 1620-1624https://doi.org/10.1016/j.jaccas.2020.04.010
        • Damluji A.A.
        • van Diepen S.
        • Katz J.N.
        • et al.
        Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association.
        Circulation. 2021; 144: e16-e35
        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013. 2013; 127: e362-425
        • Honda S.
        • Asaumi Y.
        • Yamane T.
        • et al.
        Trends in the clinical and pathological characteristics of cardiac rupture in patients with acute myocardial infarction over 35 years.
        J Am Heart Assoc. 2014; 3: e000984
        • Formica F.
        • Mariani S.
        • Singh G.
        • et al.
        Postinfarction left ventricular free wall rupture: a 17-year single-centre experience.
        Eur J Cardiothorac Surg. 2018; 53: 150-156
        • FitzGibbon G.M.
        • Hooper G.D.
        • Heggtveit H.A.
        Successful surgical treatment of postinfarction external cardiac rupture.
        J Thorac Cardiovasc Surg. 1972; 63: 622-630
        • Matteucci M.
        • Fina D.
        • Jiritano F.
        • et al.
        Treatment strategies for post-infarction left ventricular free-wall rupture.
        Eur Heart J Acute Cardiovasc Care. 2019; 8: 379-387
        • Damluji A.A.
        • Forman D.E.
        • van Diepen S.
        • et al.
        Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association.
        Circulation. 2020; 141: e6-e32
        • Dudiy Y.
        • Jelnin V.
        • Einhorn B.N.
        • Kronzon I.
        • Cohen H.A.
        • Ruiz C.E.
        Percutaneous closure of left ventricular pseudoaneurysm.
        Circ Cardiovasc Interv. 2011; 4: 322-326
        • Inayat F.
        • Ghani A.R.
        • Riaz I.
        • et al.
        Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management.
        J Investig Med High Impact Case Rep. 2018; 6 (2324709618792025-2324709618792025)
        • Mackenzie J.W.
        • Lemole G.M.
        Pseudoaneurysm of the left ventricle.
        Tex Heart Inst J. 1994; 21: 296-301
        • Yeo T.C.
        • Malouf J.F.
        • Oh J.K.
        • Seward J.B.
        Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm.
        Ann Intern Med. 1998; 128: 299-305
        • Prifti E.
        • Bonacchi M.
        • Baboci A.
        • et al.
        Surgical treatment of post-infarction left ventricular pseudoaneurysm: Case series highlighting various surgical strategies.
        Ann Med Surg (Lond). 2017; 16: 44-51