Objective: To characterize the risk profile, management and outcomes of a population with STEMI and acute MR treated in a university hospital with a primary angioplasty program.
Methodology: A total of four hundred were consecutively referred for primary angioplasty to our center from April 2017 to April 2018. Of them, two hundred and thirty-six patients were admitted to the acute cardiac care unit after confirming the diagnosis of STEMI. During hospitalization five cases (2.1%) of severe acute MR who developed cardiogenic shock were diagnosed. We describe their baseline characteristics, their treatment and evolution.
Results: The patients had an average age of 71 +/- 11 years, and 60% (n=3) were women. Most of them (4 out of 5) had a history of high blood pressure. The mean duration from the onset of symptoms to medical evaluation was 10 +/- 8 hours. The right coronary artery was the responsible in 60% of cases and the circumflex artery in the remaining 40%. The mean high sensitive Troponin I peak was 50 +/- 15 ng/ml (normal value < 0.017). All patients were admitted with signs of heart failure (Killip> = 2), and 4 out of the 5 required orotracheal intubation with mechanical ventilation. An intra-aortic balloon pump was implanted in 60% of the patients, and all patients needed vasoactive support (dobutamine plus noradrenaline). The transesophageal echocardiography showed a complete rupture of the papillary muscle in only one patient. The remaining patients exhibited displacement of the papillary muscle due to dyskinetic wall motion. An urgent surgical intervention was indicated in three cases and, in the remaining cases, medical treatment was selected due to high comorbidity and high surgical risk. Regarding surgery cases: one patient died before mitral valve surgery; in the other two cases, mitral valve replacement surgery was performed successfully: It carried out replacement with biological and mechanical mitral valve prosthesis each one. One of the procedures involved a mini-thoracotomy (port access). Regarding cases with medical management: One patient died of refractory cardiogenic shock and the other was discharged with medical treatment. The in-hospital survival rate was 60%, and it rose to 100% in patients who underwent mitral valve surgery.
Conclusions: Mortality among STEMI patients with acute severe MR and cardiogenic shock remains very high in the age of the primary angioplasthy. An early invasive and surgical approach could improve the prognosis.