Ventricular free-wall rupture, ventricular pseudoaneurysm, and papillary muscle rupture complicating acute myocardial infarction

The prevalence of mechanical complications following acute myocardial infarction has steadily declined in recent years owing to advances in prompt coronary revascularization, and they now occur in <1% of acute myocardial infarction cases. Nevertheless, significant haemodynamic impairment may already be present at hospital admission, requiring immediate diagnostic evaluation and urgent intervention. Until recently, surgical repair was the only treatment option, with non-negligible in-hospital mortality rates, particularly among patients with acute cardio-circulatory failure. Advances in transcatheter percutaneous procedures have now introduced alternative treatment strategies, especially for high-risk or inoperable patients. Recurrence of post-acute myocardial infarction mechanical complications, even shortly after the repair of the underlying lesion, has a critical impact on patient outcome and underscores the need for careful monitoring during hospitalization as well as after discharge. The role of concomitant coronary revascularization remains controversial, with variable effects on both early and late outcomes, and warrants further investigation. Temporary mechanical circulatory support has shown encouraging results, either for pre-procedural haemodynamic stabilization ('bridge-to-procedure') or for prophylactic, extended peri-procedural support to facilitate myocardial recovery ('bridge-to-recovery'). Optimal management should be guided by a multidisciplinary Heart Team approach (including Shock Team involvement where appropriate) with integration of palliative care into the decision-making process.