Role of mechanical circulatory support in mechanical complications of acute myocardial infarction

Mechanical complications of acute myocardial infarction-ventricular septal rupture, papillary muscle rupture, and free-wall rupture-are rare (< 0.3%) but lethal, with in-hospital mortality rates of 40% to 90%.These conditions may cause cardiogenic shock and require management at high-volume surgical centers by a multidisciplinary heart team.Mechanical circulatory support (MCS), including intra-aortic balloon pump (IABP), Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) may serve as a bridge to hemodynamic stabilization before definitive surgical or percutaneous repair.IABP reduces afterload and shunt fraction, Impella provides active left ventricular unloading, and VA-ECMO provides full cardiopulmonary support in refractory shock.The 2025 American College of Cardiology/American Heart Association guidelines recommend individualized use of shortterm MCS (class IIa-IIb; level of evidence, B-C).Randomized trials of cardiogenic shock have excluded these patients; therefore, the available evidence is derived from registries and observational series subject to substantial selection bias.In postinfarction ventricular septal defect, IABP is generally considered first-line support, although VA-ECMO is often required.Delayed surgery (> 7 days) is associated with improved outcomes, although selection bias remains an important confounder.Papillary muscle rupture requires emergency surgery, with IABP used as a bridge; Impella should be used cautiously.Free-wall rupture also mandates emergency surgery; and VA-ECMO may serve as a bridge.MCS may provide time for stabilization and recovery, but no mortality benefit has been conclusively demonstrated.Optimal use requires expert multidisciplinary care.