Complications of Myocardial Infarction

  • Brandon M. Jones
  • Venu MenonEmail author


This is a case of a 61 year old woman with chest discomfort and evidence of an inferior, ST-elevation myocardial infarction, who develops persistent cardiogenic shock and respiratory failure after primary percutaneous coronary intervention. We discuss the differential diagnosis for cardiogenic shock after acute myocardial infarction (AMI) including left ventricular failure, right ventricular failure, iatrogenic causes such as over-medication or bleeding complications, and mechanical complications of AMI including ventricular septal rupture (VSR), papillary muscle rupture, and free-wall rupture with cardiac tamponade. We focus on modalities for making the diagnosis including physical exam findings, trans-thoracic echocardiography, left ventriculogram, and right-heart catheterization. Medical as well as surgical management is discussed. Finally, we explore the controversial aspects regarding the evidence for intra-aortic balloon pump use in patients with cardiogenic shock after AMI, the optimal timing of surgical repair for VSR, and percutaneous options for VSR closure.


Myocardial infarction Cardiogenic shock Mechanical complication Ventricular septal rupture VSR Papillary muscle rupture Cardiac tamponade Intra-aortic balloon pump IABP 

Supplementary material

Video 13.1

Apical ventricular septal rupture: A trans-thoracic, apical 4-chamber view of the heart showing the shunting of blood from the left ventricle to the right ventricle across an apical ventricular septal rupture in a patient with recent myocardial infarction. The patient underwent emergent surgical repair (AVI 1326 kb)

Video 13.2

Papillary muscle rupture: A trans-esophageal, mid-esophageal 4-chamber view of the heart showing rupture and flail of the papillary muscle into the left atrium. Color Doppler confirmed severe 4+ mitral regurgitation, and the patient underwent emergent surgery (AVI 3601 kb)

Video 13.3

Pre-tamponade after acute myocardial infarction: A trans-thoracic, apical 4-chamber view of the heart showing a patient with pre-tamponade physiology after the development of chest pain and ST changes. The echocardiogram demonstrated atrial inversion and diastolic collapse of the right ventricle. Pericardiocentesis showed a large, hemorrhagic effusion (AVI 4141 kb)

Video 13.4

Severe mitral regurgitation due to restriction of the posterior leaflet: A trans-thoracic, parasternal long-axis view of the heart in a patient with a prior inferior myocardial infarction. The inferior wall is akinetic resulting in restricted motion of the posterior mitral leaflet and severe mitral regurgitation (AVI 1928 kb)


  1. 1.
    Hochman JS, Sleeper LA, White HD, Dzavik V, Wong SC, Menon V, et al. One-year survival following early revascularization for cardiogenic shock. JAMA. 2001;285(2):190–2.CrossRefPubMedGoogle Scholar
  2. 2.
    Menon V, Hochman JS. Management of cardiogenic shock complicating acute myocardial infarction. Heart. 2002;88(5):531–7.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    French JK, Hellkamp AS, Armstrong PW, Cohen E, Kleiman NS, O’Connor CM, et al. Mechanical complications after percutaneous coronary intervention in ST-elevation myocardial infarction (from APEX-AMI). Am J Cardiol. 2010;105(1):59–63.CrossRefPubMedGoogle Scholar
  4. 4.
    Jones BM, Kapadia SR, Smedira NG, Robich M, Tuzcu EM, Menon V, et al. Ventricular septal rupture complicating acute myocardial infarction: a contemporary review. Eur Heart J. 2014;35(31):2060–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Arnaoutakis GJ, Zhao Y, George TJ, Sciortino CM, McCarthy PM, Conte JV. Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database. Ann Thorac Surg. 2012;94(2):436–43; discussion 43–4.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Tsai MT, Wu HY, Chan SH, Luo CY. Extracorporeal membrane oxygenation as a bridge to definite surgery in recurrent postinfarction ventricular septal defect. ASAIO J. 2012;58(1):88–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Neragi-Miandoab S, Michler RE, Goldstein D, D’Alessandro D. Extracorporeal membrane oxygenation as a temporizing approach in a patient with shock, myocardial infarct, and a large ventricle septal defect; successful repair after six days. J Card Surg. 2013;28(2):193–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Thiele H, Kaulfersch C, Daehnert I, Schoenauer M, Eitel I, Borger M, et al. Immediate primary transcatheter closure of postinfarction ventricular septal defects. Eur Heart J. 2009;30(1):81–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Assenza GE, McElhinney DB, Valente AM, Pearson DD, Volpe M, Martucci G, et al. Transcatheter closure of post-myocardial infarction ventricular septal rupture. Circ Cardiovasc Interv. 2013;6(1):59–67.CrossRefPubMedGoogle Scholar
  10. 10.
    Holzer R, Balzer D, Amin Z, Ruiz CE, Feinstein J, Bass J, et al. Transcatheter closure of postinfarction ventricular septal defects using the new Amplatzer muscular VSD occluder: Results of a U.S. Registry. Catheter Cardiovasc Interv. 2004;61(2):196–201.CrossRefPubMedGoogle Scholar
  11. 11.
    Maltais S, Ibrahim R, Basmadjian AJ, Carrier M, Bouchard D, Cartier R, et al. Postinfarction ventricular septal defects: towards a new treatment algorithm? Ann Thorac Surg. 2009;87(3):687–92.CrossRefPubMedGoogle Scholar
  12. 12.
    Bialkowski J, Szkutnik M, Zembala M. Ventricular septal defect closure – importance of cardiac surgery and transcatheter intervention. Kardiol Pol. 2007;65(8):1022–4.PubMedGoogle Scholar
  13. 13.
    Demkow M, Ruzyllo W, Kepka C, Chmielak Z, Konka M, Dzielinska Z, et al. Primary transcatheter closure of postinfarction ventricular septal defects with the Amplatzer septal occluder- immediate results and up-to 5 years follow-up. EuroIntervention. 2005;1(1):43–7.PubMedGoogle Scholar
  14. 14.
    Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287–96.CrossRefPubMedGoogle Scholar
  15. 15.
    O’Gara PT, Kushner FG, Ascheim DD, Casey Jr DE, Chung MK, de Lemos JA, et al. 2013 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. J Am Coll Cardiol. 2013;61(4):e78–140.CrossRefPubMedGoogle Scholar
  16. 16.
    Chesebro JH, et al. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987;76(1):142–54.CrossRefPubMedGoogle Scholar
  17. 17.
    Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol. 1967;20(4):457–64.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Cardiovascular Medicine and Interventional CardiologyCleveland Clinic FoundationClevelandUSA
  2. 2.Pulmonary and Critical CareGeisinger Medical CenterDanvilleUSA

Personalised recommendations