Complications after acute myocardial infarction — viva

Stem

Practice viva. The examiner describes a patient who deteriorates a few days after an acute myocardial infarction, and works through recognition, imaging, circulatory support and repair of mechanical complications, then LV thrombus and pericardial complications.^[1]

Branch A — Recognition

Examiner: When do you suspect a mechanical complication, and when do they occur?^[1]

Strong answer:

• ESC 2023 says sudden hypotension, recurrence of chest pain, new murmurs suggestive of acute mitral regurgitation or a ventricular septal defect, pulmonary congestion or jugular vein distension should raise suspicion.^[1]
• ESC 2023 says they may occur in the first days after MI, most commonly with STEMI; ACC/AHA 2025 says they commonly present within the first week after an acute MI.^[1][2]
• The AHA 2021 statement places papillary muscle rupture at 3–5 days, and ventricular septal defect and free-wall rupture commonly at 3–5 days, after a transmural infarct (its Table 1).^[7]
• ESC 2023 reports a recent large epidemiological investigation of almost 9 million ACS patients in which mechanical complications occurred in 0.27% of STEMI and 0.06% of NSTEMI cases, with in-hospital mortality of 42.4% and 18%, respectively.^[1]

Follow-up: Why does an inferior STEMI tear the posteromedial papillary muscle?^[7]

• The AHA 2021 statement says the posteromedial muscle has a single blood supply from the circumflex or the right coronary artery, depending on dominance, whereas the anterolateral muscle has a dual supply.^[7]
• So anterolateral rupture is extremely uncommon, and posteromedial rupture typically occurs with inferior or lateral STEMI; a murmur may be absent because left atrial and LV pressures equalise rapidly.^[7]

Branch B — Imaging and the first hour

Examiner: What do you do first?^[1]

Strong answer:

• ESC 2023: emergency TTE is recommended in suspected ACS with cardiogenic shock or suspected mechanical complications (Class I, Level C).^[1]
• ESC 2023: with haemodynamic instability, emergency surgical or catheter-based repair is recommended, based on Heart Team discussion (Class I, Level C).^[1]
• ACC/AHA 2025: a mechanical complication of ACS should be managed in a facility with cardiac surgical expertise (COR 1, LOE C-EO), and a Heart Team approach to the feasibility, timing and nature of correction and to the need for and selection of MCS is recommended as soon as the complication is diagnosed (supportive text).^[2]

Follow-up: The patient is in shock and a primary PCI is more than 2 hours away. Can you give fibrinolysis?^[1]

• ESC 2023 says fibrinolysis should be considered in STEMI with cardiogenic shock if a PPCI strategy is not available within 120 min of STEMI diagnosis and mechanical complications have been ruled out (Class IIa, Level C).^[1]

Branch C — Circulatory support

Examiner: IABP-SHOCK II was negative. Why would you use a balloon pump?^[7]

Strong answer:

• The AHA 2021 statement says the IABP-SHOCK II trial, which showed no mortality benefit from an IABP in acute MI with cardiogenic shock, excluded patients with mechanical complications.^[7]
• ESC 2023 says routine IABP use in ACS with cardiogenic shock and without mechanical complications is not recommended (Class III, Level B), but an IABP should be considered with haemodynamic instability or shock due to ACS-related mechanical complications (Class IIa, Level C).^[1]
• ACC/AHA 2025 says an IABP has been shown to reduce left-to-right shunting and improve haemodynamics in ventricular septal rupture, with and without shock.^[2]
• ESC 2026, in its table on temporary MCS in cardiogenic shock, says temporary MCS should be considered for MI-related mechanical complications as a bridge to definitive treatment (Class IIa, Level C), with passive IABP or active percutaneous MCS chosen by the Shock Team on shock severity.^[3]

Follow-up: Any device you would avoid?^[3]

• ESC 2026: in a large ventricular septal defect, temporary MCS should be used with caution, because of a potential increase in left-to-right shunt with VA-ECLS or shunt inversion with a microaxial flow pump.^[3]
• In free-wall rupture temporary MCS should be avoided; however, VA-ECLS can be considered to allow emergent surgery in profound cardiogenic shock and/or cardiac arrest if there is no sign of irreversible brain injury.^[3]
• ACC/AHA 2025 reports a National Inpatient Sample analysis of 10,726 patients with post-STEMI mechanical complications in which VA-ECMO was associated with increased in-hospital mortality, with the caveat that VA-ECMO at any time in the admission, including after surgery, was counted.^[2]

Branch D — Repair

Examiner: Operate now or later?^[2]

Strong answer:

• ACC/AHA 2025 says that, although the exact timing remains uncertain, early corrective surgery is the treatment of choice; overall surgical mortality is approximately 40%.^[2]
• Surgical risk is highest in cardiogenic shock and appears lower when surgery is delayed; mortality after delayed surgery (more than 7 days) is lower, but patient selection and survivor bias contribute.^[2]
• For a ventricular septal defect, the AHA 2021 statement says emergency surgery is indicated for cardiogenic shock and/or pulmonary oedema refractory to MCS, and suggests delaying surgery when feasible in a haemodynamically stable patient without respiratory failure.^[7]
• ESC 2023 narrative: CABG is recommended at the time of surgical repair when coronary revascularisation is needed; NHFA/CSANZ 2025 says perform CABG at the time of surgery in STEMI or ACOMI with mechanical complications and mitral valve disease (strong recommendation, low certainty).^[1][6]

Branch E — LV thrombus and the pericardium

Examiner: After a large anterior STEMI, how do you look for and treat LV thrombus?^[2]

Strong answer:

• ESC 2023: echocardiography is the first-line test; CMR should be considered with equivocal echocardiographic images or in cases of high clinical suspicion of LV thrombus (Class IIa, Level C); after an acute anterior MI, a contrast echocardiogram may be considered for the detection of LV thrombus if the apex is not well visualised (Class IIb, Level C).^[1]
• ESC 2023 says identification of LV thrombus has been reported to increase in the first 2 weeks after MI, and that, while more contemporary data are required, delayed imaging at 2 weeks in high-risk patients may be of value.^[1]
• ESC 2023: oral anticoagulant therapy (VKA or NOAC) should be considered for 3–6 months in confirmed LV thrombus (Class IIa, Level C); ACC/AHA 2025 says most patients warrant anticoagulation for 3 months, with repeat imaging to judge whether a longer course is warranted.^[1][2]

Follow-up: And pericarditis after MI?^[1]

• ESC 2023 says the pericardial complications that may develop after an acute MI include early infarct-associated pericarditis (a few hours to 4 days, mostly transient), late pericarditis or post-cardiac injury (Dressler) syndrome (typically 1–2 weeks after acute MI) and pericardial effusion.^[1]
• ESC 2025: in early post-AMI pericarditis a 5–7-day course of aspirin, with colchicine, seems the most reasonable option; in its post-cardiac injury syndrome recommendations, high-dose aspirin is recommended as the first-choice anti-inflammatory therapy for post-MI pericarditis and in patients already on antiplatelet therapy (Class I, Level C). ACC/AHA 2025 calls glucocorticoids and NSAIDs other than aspirin potentially harmful.^[4][2]
• ESC 2025: a post-MI effusion over 10 mm at end-diastole should be investigated for possible subacute heart rupture.^[4]