Role of Interventional Echocardiography in Mechanical Complications in ACS

At the present time, with development of primary PCI procedure the mechanical complications of myocardial infarction (MI) are relatively rare but unfortunately with high mortality rate. Post MI ventricular septal rupture (VSR) is a devastating complication of ST elevation MI. Although surgical intervention is considered the gold standard for treatment, it carries high morbidity and mortality rates. As a result, attention has turned to percutaneous options for the closure of VSR in patients with significant risk for surgical repair, either as a definitive strategy, or as a bridge to surgery after initial stabilization. Papillary muscle rupture (PMR) is also a catastrophic complication of acute MI. It can lead to acute MR, pulmonary edema, cardiogenic shock, or some combination of these findings. If PMR is untreated, the prognosis is poor and the mortality could be as high as 80%. For patients with PMR, the standard therapy for MR is open surgical repair or replacement. Percutaneous mitral valve repair using Mitraclip has recently emerged as an alternative to surgery for the treatment of severe MR. There are a few case reports with successful results. Left ventricular pseudoaneurysm due to acute MI is infrequent but fatal complication that occur especially during the 1st week of MI. Surgical intervention is essential but conveys significant operative mortality so catheter-based closure of the ruptured segment may be an alternative to surgery especially in patients with high surgical risk. Multimodality imaging especially echocardiography has significant pivotal role in all of these transcatheter procedures.