Cardiac rupture in acute myocardial infarction: a cardiac magnetic resonance study

Q: What are the key findings of this study?

Cardiac magnetic resonance safely diagnosed post-AMI cardiac rupture, showing higher rates of pericardial enhancement, MVO, and worse strain than controls.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Acute myocardial infarction with clinical suspicion of cardiac rupture (n=38). Intervention: Cardiac rupture complicating acute myocardial infarction evaluated by cardiac magnetic resonance (CMR) vs. Matched acute myocardial infarction patients without cardiac rupture. Primary outcome: Pericardial enhancement on cardiac magnetic resonance (p=<0.001).

Q: What does this research mean for the field?

Cardiac magnetic resonance safely identifies post-acute myocardial infarction cardiac rupture, which is characterized by significantly higher rates of microvascular obstruction, pericardial enhancement, intramyocardial hemorrhage, and impaired myocardial strain compared with uncomplicated infarction. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To assess the feasibility of cardiac magnetic resonance and the diagnostic value of myocardial strain and wall stress parameters in patients with acute myocardial infarction and suspected cardiac rupture.

Manuel De Lazzari; Alberto Cipriani; Annagrazia Cecere; Alice Niero; Monica De Gaspari; Benedetta Giorgi; Giorgio Conti; Raffaella Motta; Stefania Rizzo; Francesco Tona; Luisa Cacciavillani; Giuseppe Tarantini; Gino Gerosa; Cristina Basso; Sabino Iliceto; Martina Perazzolo Marra

doi:10.1093/ehjci/jead088

May 18, 2023European Heart Journal - Cardiovascular ImagingOpen Access

Cardiac rupture in acute myocardial infarction: a cardiac magnetic resonance study

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Key result

CMR safely identifies post-AMI cardiac rupture, characterized by a ~5-fold higher rate of pericardial enhancement.

P<0.001
n=38

Figures

Graphical abstract published by European Heart Journal - Cardiovascular Imaging — Graphical abstract · Published by European Heart Journal - Cardiovascular Imaging · CC BY-NC

Why the study?

The feasibility of CMR and the role of myocardial strain in the diagnostic work-up of patients with AMI and suspected cardiac rupture required assessment.

Does cardiac magnetic resonance with myocardial strain analysis identify distinct tissue and deformation abnormalities in acute myocardial infarction patients complicated by cardiac rupture compared to matched controls without rupture?

Key Points

To assess the feasibility of cardiac magnetic resonance and the diagnostic value of myocardial strain and wall stress parameters in patients with acute myocardial infarction and suspected cardiac rupture.
Enrolled 19 consecutive patients with acute myocardial infarction complicated by cardiac rupture (63% male, median age 73 years) and a control group of 19 patients with acute myocardial infarction without rupture who underwent cardiac magnetic resonance.
Evaluated standard cardiac magnetic resonance tissue parameters alongside 2D and 3D strain analyses and calculated relative wall stress index and wall stress index ratio between infarcted and adjacent myocardial segments.
Microvascular obstruction (P = 0.001), pericardial enhancement (P < 0.001), and intramyocardial haemorrhage (P = 0.003) were significantly more frequent in patients with cardiac rupture than in controls.
Patients with cardiac rupture showed lower 2D and 3D global radial strain (17 vs. 31, P < 0.001; 22 vs. 31, P = 0.001), lower global circumferential strain (-10 vs. -16, P < 0.001; -9 vs. -13, P = 0.001), and lower 3D global longitudinal strain (-7 vs. -11, P < 0.001) compared to controls.
Patients with cardiac rupture had significantly higher 2D circumferential wall stress index (-7 vs. -3, P = 0.010), higher 2D and 3D circumferential wall stress index ratios (2 vs. 0.2, P < 0.001; 1 vs. 1, P = 0.042), and higher 2D and 3D radial wall stress index ratios (2 vs. 1, P < 0.001; 2 vs. 1, P = 0.007).

Study Design

Type

Cohort (n=38)

Multicenter

No

Structured PICO

Does cardiac magnetic resonance with myocardial strain analysis identify distinct tissue and deformation abnormalities in acute myocardial infarction patients complicated by cardiac rupture compared to matched controls without rupture?

P

Population

38 patients admitted for acute myocardial infarction (19 with confirmed or clinically suspected cardiac rupture, median age 73 years, 37% female, and 19 matched controls without rupture) undergoing acute-phase cardiac magnetic resonance imaging at a single Italian center.

E

Exposure

Cardiac magnetic resonance (CMR) using a 1.5 T scanner in the acute phase (days 1 to 10 after admission) with traditional tissue characterization (LGE, T2-weighted imaging) and 2D/3D feature-tracking myocardial strain analysis (including wall stress index [WSI] and WSI ratio) in patients with cardiac rupture

C

Comparator

Matched control group of patients admitted for acute myocardial infarction without mechanical complications (cardiac rupture, aneurysms, or pseudoaneurysms) undergoing the same CMR protocol

O

Outcome

Traditional CMR tissue abnormalities (pericardial enhancement, microvascular obstruction [MVO], intramyocardial haemorrhage) and 2D/3D global and regional myocardial strain parameters (GRS, GCS, GLS, WSI, and WSI ratio)surrogate

Main Result

Absolute Event Rate: 78% vs 16%

p-value: p=<0.001

CMR is a safe and effective diagnostic modality in clinically stable patients with suspected post-AMI cardiac rupture, identifying microvascular obstruction, pericardial enhancement, and increased border-zone wall stress as key pathophysiological markers.

Limitations

Single-center retrospective design with a small sample size (n=19 cases, n=19 controls)
Exclusion of 15 patients due to severe clinical instability, contraindications, or poor image quality
Potential overestimation of infarct size and transmurality due to acute phase edema and inflammation
Wide range of normal myocardial strain values and variability in global radial strain
Lack of T1, T2, and T2 parametric mapping techniques at the time of enrollment
Single-center study with a small sample size limiting statistical power
Selection bias due to exclusion of clinically unstable patients unable to undergo CMR
Overestimation of infarct size and transmurality on CMR during the acute phase due to myocardial edema and inflammation
Intrinsic variability in myocardial deformation and global radial strain assessment
Lack of T1, T2, and T2 mapping sequences at the time of patient enrollment

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Implication

CMR may aid diagnosis of post-AMI rupture in stable patients; leaves open whether strain or wall stress improves prospective risk stratification.

Abstract

AIMS: We assessed the feasibility of cardiac magnetic resonance (CMR) and the role of myocardial strain in the diagnostic work-up of patients with acute myocardial infarction (AMI) and a clinical suspicion of cardiac rupture (CR). METHODS AND RESULTS: Consecutive patients with AMI complicated by CR who underwent CMR were enrolled. Traditional and strain CMR findings were evaluated; new parameters indicating the relative wall stress between AMI and adjacent segments, named wall stress index (WSI) and WSI ratio, were analysed. A group of patients admitted for AMI without CR served as control. 19 patients (63% male, median age 73 years) met the inclusion criteria. Microvascular obstruction (MVO, P = 0.001) and pericardial enhancement (P < 0.001) were strongly associated with CR. Patients with clinical CR confirmed by CMR exhibited more frequently an intramyocardial haemorrhage than controls (P = 0.003). Patients with CR had lower 2D and 3D global radial strain (GRS) and global circumferential strain (in 2D mode P < 0.001; in 3D mode P = 0.001), as well as 3D global longitudinal strain (P < 0.001), than controls. The 2D circumferential WSI (P = 0.010), as well as the 2D and 3D circumferential (respectively, P < 0.001 and P = 0.042) and radial WSI ratio (respectively, P < 0.001 and P: 0.007), were higher in CR patients than controls. CONCLUSION: CMR is a safe and useful imaging tool to achieve the definite diagnosis of CR and an accurate visualization of tissue abnormalities associated with CR. Strain analysis parameters can give insights into the pathophysiology of CR and may help to identify those patients with sub-acute CR.

Discussion

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Cite This Study

Lazzari et al. (2023) conducted a cohort in Acute myocardial infarction with clinical suspicion of cardiac rupture (n=38). Cardiac rupture complicating acute myocardial infarction evaluated by cardiac magnetic resonance (CMR) vs. Matched acute myocardial infarction patients without cardiac rupture was evaluated on Pericardial enhancement on cardiac magnetic resonance (p=<0.001). Cardiac magnetic resonance safely diagnosed post-AMI cardiac rupture, showing higher rates of pericardial enhancement, MVO, and worse strain than controls.

synapsesocial.com/papers/6a7af1a874c579e25f8947b9 https://doi.org/10.1093/ehjci/jead088

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Cardiac rupture in acute myocardial infarction: a cardiac magnetic resonance study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Cardiac rupture in acute myocardial infarction: a cardiac magnetic resonance study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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