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Vol. 69. Issue 9.
Pages 874-876 (September 2016)
Scientific letter
DOI: 10.1016/j.rec.2016.04.032
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Incidence and Prognosis of Mechanical Complications of STEMI After Primary Angioplasty: Data From a Single-center Registry of an Infarction Code Program
Incidencia y pronóstico de las complicaciones mecánicas del IAMCEST sometido a angioplastia primaria: datos de un registro unicéntrico de Código Infarto
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Javier Navarro-Cuartero, Juan Gabriel Córdoba-Soriano
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jgcordobas@hotmail.com

Corresponding author:
, Jesús Jiménez-Mazuecos, Antonio Gutiérrez-Díez, Arsenio Gallardo-López, Driss Melehi
Servicio de Cardiología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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Tables (2)
Table 1. Baseline Characteristics of Patients With and Without Mechanical Complications and Their Comparison
Table 2. Characteristics of Patients With Mechanical Complications
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To the Editor,

Mechanical complications (MC) of ST-segment-elevation acute myocardial infarction (STEMI) are an important cause of morbidity and mortality and dramatically worsen prognosis. The introduction of early reperfusion therapy has significantly reduced the classical incidence of MC (5%-10%).1,2 In particular, the widespread use of primary angioplasty (PA) has reduced its current incidence to between 1% and 2%.3,4 The implementation of regional PA programs has decreased reperfusion times and improved prognosis, most likely due to the decreased incidence of MC. We evaluated the incidence, treatment, course, and predictors of MC in a cohort who underwent PA under a STEMI emergency treatment protocol, in which fibrinolysis was only used when there were delays or logistic difficulties.

Four researchers retrospectively reviewed the medical records of 950 consecutive patients who underwent PA between 2005 and 2012 with hospital and 30-day follow-up. Qualitative variables are expressed as percentages and quantitative variables as mean or median ± standard deviation according to the normality of the distribution. The Student t test was used to compare means and chi-square for percentages. Univariable and multivariable analyses were used to identify the predictors of MC. A P value of < .05 was used as a cutoff for statistical significance.

The incidence of MC was 2.02% (19 patients). Of these patients, 14 (73.6%) had free wall rupture (FWR), 2 (10.5%) had interventricular septal rupture (IVSR), and 3 (15.8%) had papillary muscle rupture (PMR). Most MCs occurred within 24hours of admission (52.6%) and a significant proportion (26.3%) occurred after 96hours. Table 1 shows the baseline characteristics of the patients and Table 2 shows the characteristics of the patients with MCs. The median total times of ischemia (symptoms-to-balloon) and door-to-balloon were nonsignificantly higher in the MC group. Regarding treatment and in-hospital course, 7 patients died (36.8%) and 10 patients (52.6%) were referred to cardiac surgery. One patient died before surgery, but the remaining 9 patients survived. All patients with PMR or IVSR underwent surgery, whereas 5 (35.7%) of the patients with FWR underwent surgery and 5 with FWR (35.7%) underwent intensive medical treatment. Patients with IVSR did not undergo percutaneous treatment due to its lack of availability. These treatment options were not applicable in the remaining patients with FWR (28.6%), because of sudden death. Logistic regression analysis showed that the only independent predictors of events were female sex (odds ratio [OR] = 4.03; confidence interval 95% [95%CI], 1.2-14.9; P = .022) and Killip class III-IV (OR = 1.95; 95%CI, 1.9-4.5; P < .0001).

Table 1.

Baseline Characteristics of Patients With and Without Mechanical Complications and Their Comparison

  MC (n = 19)  Without MC (n = 931)  P 
Age, y  76.8±8.9  65±13.5  <.01 
Men, %  52.6  80.2  <.01 
BMI  25.3  28.2  .54 
HT, %  52.6  59.5  .54 
DM, %  36.8  26.4  .77 
Dyslipidemia, %  57.9  42.9  .19 
Smoking, %  41.2  21.1  .12 
Previous ischemic heart disease, %  5.3  11.7  .38 
Peripheral artery disease, %  8.3  .19 
CCR < 60 mL/min, %  20.1  17  .22 
Site of AMI      .35 
Anterior/septal, %  61.1  44.4   
Inferior/posterior, %  16.7  25.7   
Lateral, %  3.3  9.8   
Other, %  18.9  20.1   
Culprit artery      .79 
LMCA, %  0.4   
AD territory, %  57.9  43.7   
RC territory, %  31.7  44.2   
Cx territory, %  10.4  11.7   
Killip class ≥ III, %  68.8  12.1  <.01 
Multivessel disease, %  57.9  57.6  .97 
Total ischemia time, min  360 [210-448]  240 [170-350]  .62 
Door-to-balloon time, min  87 [46-210]  70 [36-120]  .18 
IABPC, %  5.3  2.2  .37 
Hospital mortality, %  36.8  4.0  <.01 

AD, anterior descending; AMI, acute myocardial infarction; BMI, body mass index; CCR, creatinine clearance rate; Cx, circumflex; DM, diabetes mellitus; HT, hypertension; IABCP, intra-aortic balloon counter pulsation; LMCA, left main coronary artery; MC, mechanical complication; RC, right coronary.

Unless otherwise specified, values are expressed as mean ± standard deviation or median [interquartile range].

Table 2.

Characteristics of Patients With Mechanical Complications

Patient  Type of MC  Year of MC  Moment of MCa  Sex  Age, y  CA  Killip class at admission  LVEF at admission, %  Successful PCIb  TTI, min  DBT, min  CVS  Mortality   
                          Hospital  30 d 
FWR  2005  3rd day  Woman  82  RCd  IV  60  No  460  320  Noc  Yes  — 
IVSR  2006  1st day  Man  85  ADi  40  Yes  420  NA  Yes  Yes   
FWR  2006  4th day  Woman  83  ADi  IV  NA  No  210  90  No  Yes  — 
FWR  2007  1st day  Man  74  RCp  55  Yes  360  180  Yes  No  No 
FWR  2007  11th day  Man  43  ADp  III  25  Yes  > 48 h  NA  Yes  No  No 
FWR  2008  2nd day  Man  79  RCp  IV  55  Yes  210  30  Yes  No  No 
FWR  2008  1st day  Man  77  ADp  IV  35  Yes  360  220  No  No  No 
PMR  2009  1st day  Man  87  RCi  IV  60  Yes  240  45  Yes  Yes  — 
FWR  2009  8th day  Man  83  ADp  II  35  Yes  300  50  No  No  No 
10  FWR  2010  1st day  Woman  79  ADi  IV  30  Yes  420  40  Noc  Yes  — 
11  FWR  2010  1st day  Woman  73  OM2  II  NA  Yes  240  180  Noc  Yes  — 
12  FWR  2010  3rd day  Woman  80  ADp  IV  30  No  360  75  No  No  No 
13  FWR  2010  5th day  Woman  83  ADd  II  45  No  390  100  Yes  No  No 
14  FWR  2011  4th day  Man  80  ADp  IV  30  Yes  210  90  Yes  No  No 
15  FWR  2011  1st day  Man  76  ADp  NA  No  330  —  Noc  Yes  — 
16  FWR  2012  3rd day  Woman  81  RCp  55  Yes  150  45  No  No  No 
17  PMR  2012  1st day  Man  79  CX-OM1  III  70  Yes  90  75  Yes  No  No 
18  PMR  2012  1st day  Woman  68  RCi  IV  60  Yes  510  55  Yes  No  No 
19  IVSR  2012  1st day  Woman  78  ADi  IV  50  Yes  720  120  Yes  No  No 

AD, anterior descending; CA, culprit artery; CVS, cardiovascular surgery; CX-OM1, circumflex-first marginal; d, distal; DBT, door-to-balloon time; FWR, free wall rupture; i, intermediate; IVSR, interventricular septal rupture; LVEF, left ventricular ejection fraction; MC, mechanical complication; NA, not available; OM2, second marginal; p, proximal; PCI, percutaneous coronary intervention; PMR, papillary muscle rupture; RC, right coronary; TIMI, Thrombolysis in Myocardial Infarction; TTI, total time of ischemia.

a

Time of MC after admission.

b

PCI was considered successful if it was possible to revascularize the culprit artery without complications and with TIMI III flow.

c

CVS not scheduled due to abrupt clinical presentation of MC as sudden death.

The incidence of MC was similar to that described in the literature1,2, but clearly lower than its incidence (5%-10%) in the period before widespread implementation of systematic reperfusion. Some characteristics have already been described as predictors of MC: female sex and longer ischemia times.4 In our series, Killip class III-IV was also an independent predictor of MC.

Current guidelines5 recommend surgery as the treatment of choice; however, some patients are not candidates for emergency surgery because of instability, age, and comorbidity. In addition, the optimal timing of surgical treatment remains to be established. Surgical mortality in these patients is considerable and is clearly influenced by those who survive the first days of stabilization under intensive measures, which constitutes a selection bias in most of the reported results. In our series, 52.6% of patients were referred to surgery, and around half of the patients with FWR received intensive medical treatment with acceptable results. Most of these patients had subacute FWR, which successfully responds to nonsurgical treatment.6

Regardless of treatment, prognosis is clearly worse in these patients and depends on the type of MC. In a series published by French et al.,4 in-hospital survival and 90-day survival were 97% and 96% in patients without MC, respectively. However, in-hospital survival and 90-day survival were 43% and 27% in patients with FWR, 73% and 73% in those with PMR, and 60% and 20% in those with IVSR, respectively. Overall 30-day survival was 63.2%, which varied according to the type of MC: 64.3% in FWR, 66.6% in PMR, and 50% in IVSR.

In conclusion, the incidence of MC has decreased in the era of PA, but remains associated with high mortality; however, the mortality rate could decrease in a group selected for surgery. Early diagnosis and treatment would be improved by remaining alert to the specific characteristics of each patient. The incidence of MC could be reduced by the widespread use of PA protocols with shorter ischemia times. Multicenter registries with more patients are needed to better understand the predictors of MC and to determine which subgroups would derive the most benefit from surgical treatment.

References
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R.J. Goldberg, J.M. Gore, J.S. Alpert, V. Osganian, J. de Groot, J. Bade, et al.
Cardiogenic shock after acute myocardial infarction: incidence and mortality from a community wide perspective 1975-1988.
N Engl J Med, 325 (1991), pp. 1117-1122
[2]
R.J. Goldberg, N.A. Samad, J. Yarzebski, J. Gurwitz, C. Bigelow, J.M. Gore.
Temporal trends in cardiogenic shock complicating acute myocardial infarction.
N Engl J Med, 340 (1999), pp. 1162-1168
[3]
R.S. Kutty, N. Jones, N. Moorjani.
Mechanical complications of acute myocardial infarction.
Cardiol Clin., 31 (2013), pp. 519-531
[4]
J.K. French, A.S. Hellkamp, P.W. Armstrong, E. Cohen, N.S. Kleiman, C.M. O’Connor, et al.
Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction (from APEX-AMI).
Am J Cardiol., 105 (2010), pp. 59-63
[5]
G. Steg, S.K. James, D. Atar, L.P. Badano, C. Blomstrom-Lundqvist, M.A. Borger, et al.
Guía de práctica clínica de la ESC para el manejo del infarto agudo de miocardio en pacientes con elevación del segmento ST.
[6]
J. Figueras, O. Alcalde, J. Barrabés, V. Serra, J. Alguersuari, J. Cortadellas, et al.
Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period.
Circulation., 118 (2008), pp. 2783-2789
Copyright © 2016. Sociedad Española de Cardiología
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