An 82-year-old woman calls 911 after developing sudden-onset chest pain, nausea, and lightheadedness. An ECG done by emergency medical service (EMS) reveals 3-mm ST elevation in leads II, III, and aVF. The nearest catheterization laboratory is activated and the patient undergoes PCI to the right coronary artery (RCA) with drug-eluting stent. She is transferred to the intensive care unit (ICU) in stable condition after the procedure. Two days later, the patient develops sudden-onset lightheadedness and left-sided chest pain. Her vitals reveal BP of 115/60 mmHg, heart rate of 90 per minute and SaO2 of 92% on ambient air. Physical examination reveals new systolic murmur at the left sternal border that radiates to the apex. An ECG done immediately reveals Q waves in leads II, III, and aVF. No new ST-T changes are noted. A stat bedside echocardiogram reveals basal septal VSR with leftto-right shunt and moderate mitral regurgitation. A pulmonary artery (PA) catheter is placed and shunt fraction (Qp /Qs ) is calculated at 1.3.
What is the next best step in management?
Urgent surgical repair. This patient has VSR after acute MI. Although the shunt fraction is small, the rupture may rapidly progress in an unpredictable manner and lead to hemodynamic collapse and death. Although controversial, urgent surgical closure remains the treatment of choice. Vasodilators (nitroprusside) and IABP placements can reduce shunt fraction and increase forward flow and can be utilized in hemodynamically unstable patients as bridge to surgery. This patient is hemodynamically stable with a small shunt fraction.
Which of the following statements is true regarding ventricular free wall rupture complicating acute MI?
All of the above. Acute ventricular free wall rupture usually presents with acute onset cardiac tamponade, pulsus paradoxus, and sudden death. It accounts for approximately 10% of mortality after MI. Fibrinolysis may increase risk and this potentially accounts for the “early hazard” with thrombolytic therapy as noted in the randomized clinical trials. Type I rupture is a slit-like full-thickness rupture that is usually seen within the first 24 hours. It usually occurs in the border zone between the akinetic infarctrelated segment and the adjacent hyperkinetic noninfarct zone.
Which of the following is true?
Ventricular aneurysm is more common than ventricular pseudoaneurysm after MI. True ventricular aneurysm is more likely than pseudoaneurysm (contained rupture of LV free wall). While ventricular aneurysm is more likely with anterior MI, pseudoaneurysms occur more often after inferior wall MI. In contrast to patients with true aneurysms that are initially managed with medical therapy, pseudoaneurysms have a high risk of rupture and surgical therapy is recommended irrespective of size or presence/absence of symptoms.
A 63-year-old woman presents to the clinic after an episode of sudden transient left-sided vision loss. Symptoms lasted about 15 minutes with spontaneous resolution. Her past medical history is significant for an anterior MI 3 weeks ago treated with PCI with bare metal stent (BMS) to the left anterior descending artery (LAD). Other medical conditions include hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications are aspirin, prasugrel, atorvastatin, metformin, and metoprolol. Physical examination is normal. There are no carotid bruits. Ophthalmologic examination is within normal limits. An ECG reveals sinus rhythm with persistent ST elevations in V2 to V4 .
What is the next step in management?
Transthoracic echocardiogram. This patient presents with symptoms suggestive of TIA. He had a recent anterior wall MI. Persistent ST elevation in V2 to V4 suggests apical aneurysm that increases the risk of mural thrombus formation. Current symptoms suggest an embolic event secondary to LV mural thrombus. Echocardiogram must be done to confirm the diagnosis. Although the patient has persistent ST elevation on ECG, there are no clinical signs of recurrent ischemia and repeat left heart catheterization is not indicated.
A previously healthy and independently functional 77-year-old man is brought to the catheterization laboratory after developing sudden-onset chest pain radiating to the jaw and shortness of breath. ECG by EMS during transfer revealed ST elevation in V2 to V4 and leads I and aVL. The patient was in respiratory distress during transfer requiring emergent endotracheal intubation. His BP is 70/30 mmHg and heart rate is 110 per minute. Angiogram reveals fresh mural thrombus in proximal LAD, which is stented with BMS with resultant TIMI-2 flow. No significant disease is noted in the RCA and circumflex vessels. An echo reveals a left ventricular ejection fraction (LVEF) of 30% with no significant valvular pathology. He is subsequently transferred to the critical care unit (CCU) in critical condition. His current vital signs are as follows: BP 80/40 mmHg, HR 120 beats per minute, and SaO2 of 92% on 60% FiO2 . A PA catheter is placed.
Which of the following readings is associated with worst prognosis in this patient?
Pulmonary capillary wedge pressure (PCWP) 30, confidence interval (CI) 1.6. This patient has acute STEMI complicated by cardiogenic shock. Cardiogenic shock is defined as evidence of ineffective tissue perfusion arising from cardiac dysfunction supported by the presence of a systolic BP <90 mmHg, PCWP >15 mmHg, and cardiac index <2.2 L/min/kg/m2 . Classic study performed in the pre-reperfusion era by Forrester risk stratified patients with cardiogenic shock based on PCWP and CI. Patients with both elevated PCWP and low CI have worst prognosis. In the GUSTOI trial low cardiac output (and cardiac index) remained the strongest hemodynamic predictors of death in patients with cardiogenic shock.
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