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Mechanical complications of acute myocardial infarction

Roger J Laham, MD
Michael Simons, MD
Rakesh M Suri, MD, DPhil
Section Editor
Freek Verheugt, MD, FACC, FESC
Deputy Editor
Gordon M Saperia, MD, FACC


There are three major mechanical complications of acute myocardial infarction (MI): rupture of the left ventricular free wall; rupture of the interventricular septum; and the development of mitral regurgitation. One study compared 225 patients who had a first MI and experienced one of these complications to 1012 patients with a first MI without these mechanical complications [1]. Delayed hospitalization (≥24 hours), undue in-hospital physical activity, and postinfarction angina increased the risk of rupture in predisposed patients.

The clinical issues related to these mechanical problems, each of which can result in cardiogenic shock, will be reviewed here. (See "Clinical manifestations and diagnosis of cardiogenic shock in acute myocardial infarction".)

In this topic MI will refer to ST elevation MI, unless otherwise indicated.


Acute or subacute myocardial rupture is a serious and often lethal complication of ST elevation myocardial infarction (STEMI) [2].

Incidence — Rupture of the free wall of the infarcted ventricle is a relatively common finding in patients dying with an acute myocardial infarction (MI). Several large studies have found cardiac rupture in 14 to 26 percent of such patients (picture 1) [3,4]. The incidence is much lower when all patients with acute MI are considered. As an example, the National Registry of Myocardial Infarction published data on 350,755 patients in 1996 [5]. The following observations were noted:

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Literature review current through: Sep 2017. | This topic last updated: Jun 09, 2017.
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  1. Figueras J, Cortadellas J, Calvo F, Soler-Soler J. Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction: study in 225 patients with free wall, septal or papillary muscle rupture. J Am Coll Cardiol 1998; 32:135.
  2. Reeder GS. Identification and treatment of complications of myocardial infarction. Mayo Clin Proc 1995; 70:880.
  3. Stevenson WG, Linssen GC, Havenith MG, et al. The spectrum of death after myocardial infarction: a necropsy study. Am Heart J 1989; 118:1182.
  4. Pohjola-Sintonen S, Muller JE, Stone PH, et al. Ventricular septal and free wall rupture complicating acute myocardial infarction: experience in the Multicenter Investigation of Limitation of Infarct Size. Am Heart J 1989; 117:809.
  5. Becker RC, Gore JM, Lambrew C, et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol 1996; 27:1321.
  6. Patel MR, Meine TJ, Lindblad L, et al. Cardiac tamponade in the fibrinolytic era: analysis of >100,000 patients with ST-segment elevation myocardial infarction. Am Heart J 2006; 151:316.
  7. Figueras J, Alcalde O, Barrabés JA, 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 2008; 118:2783.
  8. Becker RC, Hochman JS, Cannon CP, et al. Fatal cardiac rupture among patients treated with thrombolytic agents and adjunctive thrombin antagonists: observations from the Thrombolysis and Thrombin Inhibition in Myocardial Infarction 9 Study. J Am Coll Cardiol 1999; 33:479.
  9. Moreno R, López-Sendón J, García E, et al. Primary angioplasty reduces the risk of left ventricular free wall rupture compared with thrombolysis in patients with acute myocardial infarction. J Am Coll Cardiol 2002; 39:598.
  10. Mann JM, Roberts WC. Rupture of the left ventricular free wall during acute myocardial infarction: analysis of 138 necropsy patients and comparison with 50 necropsy patients with acute myocardial infarction without rupture. Am J Cardiol 1988; 62:847.
  11. Pasternak RC, Braunwald E, Sobel BE. Acute myocardial infarction. In: Heart Disease, 4th ed, Braunwald EB (Ed), Saunders, Philadelphia 1992. p.200.
  12. Figueras J, Cortadellas J, Soler-Soler J. Left ventricular free wall rupture: clinical presentation and management. Heart 2000; 83:499.
  13. Mechanisms for the early mortality reduction produced by beta-blockade started early in acute myocardial infarction: ISIS-1. ISIS-1 (First International Study of Infarct Survival) Collaborative Group. Lancet 1988; 1:921.
  14. Purcaro A, Costantini C, Ciampani N, et al. Diagnostic criteria and management of subacute ventricular free wall rupture complicating acute myocardial infarction. Am J Cardiol 1997; 80:397.
  15. Batts KP, Ackermann DM, Edwards WD. Postinfarction rupture of the left ventricular free wall: clinicopathologic correlates in 100 consecutive autopsy cases. Hum Pathol 1990; 21:530.
  16. Oliva PB, Hammill SC, Edwards WD. Cardiac rupture, a clinically predictable complication of acute myocardial infarction: report of 70 cases with clinicopathologic correlations. J Am Coll Cardiol 1993; 22:720.
  17. López-Sendón J, González A, López de Sá E, et al. Diagnosis of subacute ventricular wall rupture after acute myocardial infarction: sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria. J Am Coll Cardiol 1992; 19:1145.
  18. Nakatsuchi Y, Minamino T, Fujii K, Negoro S. Clinicopathological characterization of cardiac free wall rupture in patients with acute myocardial infarction: difference between early and late phase rupture. Int J Cardiol 1994; 47:S33.
  19. Woldow AB, Mattleman SJ, Ablaza SG, Nakhjavan FK. Isolated rupture of the right ventricle in a patient with acute inferior wall MI. Chest 1990; 98:484.
  20. Cheriex EC, de Swart H, Dijkman LW, et al. Myocardial rupture after myocardial infarction is related to the perfusion status of the infarct-related coronary artery. Am Heart J 1995; 129:644.
  21. Honan MB, Harrell FE Jr, Reimer KA, et al. Cardiac rupture, mortality and the timing of thrombolytic therapy: a meta-analysis. J Am Coll Cardiol 1990; 16:359.
  22. Gertz SD, Kragel AH, Kalan JM, et al. Comparison of coronary and myocardial morphologic findings in patients with and without thrombolytic therapy during fatal first acute myocardial infarction. The TIMI Investigators. Am J Cardiol 1990; 66:904.
  23. Becker RC, Charlesworth A, Wilcox RG, et al. Cardiac rupture associated with thrombolytic therapy: impact of time to treatment in the Late Assessment of Thrombolytic Efficacy (LATE) study. J Am Coll Cardiol 1995; 25:1063.
  24. Morishima I, Sone T, Mokuno S, et al. Clinical significance of no-reflow phenomenon observed on angiography after successful treatment of acute myocardial infarction with percutaneous transluminal coronary angioplasty. Am Heart J 1995; 130:239.
  25. Keeley EC, de Lemos JA. Free wall rupture in the elderly: deleterious effect of fibrinolytic therapy on the ageing heart. Eur Heart J 2005; 26:1693.
  26. Bueno H, Martínez-Sellés M, Pérez-David E, López-Palop R. Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction. Eur Heart J 2005; 26:1705.
  27. Maggioni AP, Maseri A, Fresco C, et al. Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. The Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2). N Engl J Med 1993; 329:1442.
  28. Nakatani D, Sato H, Kinjo K, et al. Effect of successful late reperfusion by primary coronary angioplasty on mechanical complications of acute myocardial infarction. Am J Cardiol 2003; 92:785.
  29. McMullan MH, Maples MD, Kilgore TL Jr, Hindman SH. Surgical experience with left ventricular free wall rupture. Ann Thorac Surg 2001; 71:1894.
  30. Figueras J, Curós A, Cortadellas J, Soler-Soler J. Reliability of electromechanical dissociation in the diagnosis of left ventricular free wall rupture in acute myocardial infarction. Am Heart J 1996; 131:861.
  31. Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998; 32:557.
  32. Pierli C, Lisi G, Mezzacapo B. Subacute left ventricular free wall rupture. Surgical repair prompted by echocardiographic diagnosis. Chest 1991; 100:1174.
  33. Radford MJ, Johnson RA, Daggett WM Jr, et al. Ventricular septal rupture: a review of clinical and physiologic features and an analysis of survival. Circulation 1981; 64:545.
  34. Skehan JD, Carey C, Norrell MS, et al. Patterns of coronary artery disease in post-infarction ventricular septal rupture. Br Heart J 1989; 62:268.
  35. Prêtre R, Rickli H, Ye Q, et al. Frequency of collateral blood flow in the infarct-related coronary artery in rupture of the ventricular septum after acute myocardial infarction. Am J Cardiol 2000; 85:497.
  36. Birnbaum Y, Wagner GS, Gates KB, et al. Clinical and electrocardiographic variables associated with increased risk of ventricular septal defect in acute anterior myocardial infarction. Am J Cardiol 2000; 86:830.
  37. Hayashi T, Hirano Y, Takai H, et al. Usefulness of ST-segment elevation in the inferior leads in predicting ventricular septal rupture in patients with anterior wall acute myocardial infarction. Am J Cardiol 2005; 96:1037.
  38. Sasaki K, Yotsukura M, Sakata K, et al. Relation of ST-segment changes in inferior leads during anterior wall acute myocardial infarction to length and occlusion site of the left anterior descending coronary artery. Am J Cardiol 2001; 87:1340.
  39. Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000; 101:27.
  40. Mann JM, Roberts WC. Acquired ventricular septal defect during acute myocardial infarction: analysis of 38 unoperated necropsy patients and comparison with 50 unoperated necropsy patients without rupture. Am J Cardiol 1988; 62:8.
  41. Perloff JK, Talano JV, Ronan JA Jr. Noninvasive techniques in acute myocardial infarction. Prog Cardiovasc Dis 1971; 13:437.
  42. Vargas-Barrón J, Molina-Carrión M, Romero-Cárdenas A, et al. Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction. Am J Cardiol 2005; 95:1153.
  43. Drobac M, Schwartz L, Scully HE, Bentley-Taylor MM. Giant left atrial V-waves in post-myocardial infarction ventricular septal defect. Ann Thorac Surg 1979; 27:347.
  44. Bishop HL, Gibson RS, Stamm RB, et al. Role of two-dimensional echocardiography in the evaluation of patients with ventricular septal rupture postmyocardial infarction. Am Heart J 1981; 102:965.
  45. Smyllie JH, Sutherland GR, Geuskens R, et al. Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction. J Am Coll Cardiol 1990; 15:1449.
  46. Moursi MH, Bhatnagar SK, Vilacosta I, et al. Transesophageal echocardiographic assessment of papillary muscle rupture. Circulation 1996; 94:1003.
  47. Giuliani ER, Danielson GK, Pluth JR, et al. Postinfarction ventricular septal rupture: surgical considerations and results. Circulation 1974; 49:455.
  48. Daggett WM, Guyton RA, Mundth ED, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977; 186:260.
  49. Jones MT, Schofield PM, Dark JF, et al. Surgical repair of acquired ventricular septal defect. Determinants of early and late outcome. J Thorac Cardiovasc Surg 1987; 93:680.
  50. Davies RH, Dawkins KD, Skillington PD, et al. Late functional results after surgical closure of acquired ventricular septal defect. J Thorac Cardiovasc Surg 1993; 106:592.
  51. Lemery R, Smith HC, Giuliani ER, Gersh BJ. Prognosis in rupture of the ventricular septum after acute myocardial infarction and role of early surgical intervention. Am J Cardiol 1992; 70:147.
  52. Nishimura RA, Schaff HV, Gersh BJ, et al. Early repair of mechanical complications after acute myocardial infarction. JAMA 1986; 256:47.
  53. Litton TC, Sutton JP, Smith CW, et al. Surgical treatment of ventricular septal rupture complicating myocardial infarction. Am J Surg 1988; 155:587.
  54. Muehrcke DD, Daggett WM Jr, Buckley MJ, et al. Postinfarct ventricular septal defect repair: effect of coronary artery bypass grafting. Ann Thorac Surg 1992; 54:876.
  55. Cox FF, Plokker HW, Morshuis WJ, et al. Importance of coronary revascularization for late survival after postinfarction ventricular septal rupture. A reason to perform coronary angiography prior to surgery. Eur Heart J 1996; 17:1841.
  56. Benton JP, Barker KS. Transcatheter closure of ventricular septal defect: a nonsurgical approach to the care of the patient with acute ventricular septal rupture. Heart Lung 1992; 21:356.
  57. Lavie CJ, Gersh BJ. Mechanical and electrical complications of acute myocardial infarction. Mayo Clin Proc 1990; 65:709.
  58. Tcheng JE, Jackman JD Jr, Nelson CL, et al. Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction. Ann Intern Med 1992; 117:18.
  59. Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112:745.
  60. Picard MH, Davidoff R, Sleeper LA, et al. Echocardiographic predictors of survival and response to early revascularization in cardiogenic shock. Circulation 2003; 107:279.
  61. David TE. Techniques and results of mitral valve repair for ischemic mitral regurgitation. J Card Surg 1994; 9:274.
  62. James TN. Anatomy of the coronary arteries in health and disease. Circulation 1965; 32:1020.
  63. Barbour DJ, Roberts WC. Rupture of a left ventricular papillary muscle during acute myocardial infarction: analysis of 22 necropsy patients. J Am Coll Cardiol 1986; 8:558.
  64. Figueras J, Calvo F, Cortadellas J, Soler-Soler J. Comparison of patients with and without papillary muscle rupture during acute myocardial infarction. Am J Cardiol 1997; 80:625.
  65. Nishimura RA, Shub C, Tajik AJ. Two dimensional echocardiographic diagnosis of partial papillary muscle rupture. Br Heart J 1982; 48:598.
  66. Wei JY, Hutchins GM, Bulkley BH. Papillary muscle rupture in fatal acute myocardial infarction: a potentially treatable form of cardiogenic shock. Ann Intern Med 1979; 90:149.
  67. Manning WJ, Waksmonski CA, Boyle NG. Papillary muscle rupture complicating inferior myocardial infarction: identification with transesophageal echocardiography. Am Heart J 1995; 129:191.
  68. DiSesa VJ, Cohn LH, Collins JJ Jr, et al. Determinants of operative survival following combined mitral valve replacement and coronary revascularization. Ann Thorac Surg 1982; 34:482.
  69. Kishon Y, Oh JK, Schaff HV, et al. Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients. Mayo Clin Proc 1992; 67:1023.
  70. Russo A, Suri RM, Grigioni F, et al. Clinical outcome after surgical correction of mitral regurgitation due to papillary muscle rupture. Circulation 2008; 118:1528.
  71. Chevalier P, Burri H, Fahrat F, et al. Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation. Eur J Cardiothorac Surg 2004; 26:330.