Mechanical Complications After Acute Myocardial Infarction: Contemporary Management, Treatment Selection, and Outcomes in a 10-Year Regional Referral Network

Background: Mechanical complications (MCs) after acute myocardial infarction (AMI) are now uncommon but remain highly lethal, and contemporary data encompassing the full spectrum of rupture phenotypes are limited. Methods: We retrospectively identified all consecutive adults with post-AMI MCs managed at a tertiary regional referral center from 2015 to 2025. MCs included ventricular septal rupture (VSR), left ventricular free-wall rupture (LVFWR), contained rupture/pseudoaneurysm, and papillary muscle rupture (PMR). The primary endpoint was 30-day all-cause mortality. Exploratory analyses assessed treatment patterns by age, sex, geographical distance, and area-level income. Results: Among 59 patients (mean age 71.2 ± 10.7 years; 50.8% women), 17 (28.8%) had isolated VSR, 21 (35.6%) LVFWR, 10 (16.9%) combined VSR and contained LVFWR/pseudoaneurysm, and 11 (18.6%) PMR. Temporary mechanical circulatory support (MCS) and surgery were each used in 35 patients (59.3%). Thirty-day mortality was 59.3%. Among patients undergoing definitive invasive treatment, mortality was 45.7%. Older age was associated with higher 30-day mortality (OR per year 1.09, 95% CI 1.03–1.16), whereas surgery was associated with lower observed mortality (OR 0.22, 95% CI 0.07–0.73), acknowledging major treatment selection and survivor biases. Patients aged ≥75 years received MCS less frequently than younger patients (29.2% vs. 80.0%), and women underwent surgery less frequently than men (46.7% vs. 72.4%). Distance and area-level income were not associated with 30-day mortality. Conclusions: In a contemporary regional referral network, post-AMI MCs remained associated with extreme early mortality. Age and treatment selection were major determinants of observed outcomes, while marked age- and sex-related differences in treatment intensity warrant confirmation in larger multicenter cohorts.