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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e818

requiring intervention were higher in the ECLS versus no ECLS group. Overall, these studies do not support routine use of IABP and VA-ECMO in patients with AMI and cardiogenic shock.

9 ACS COMPLICATIONS

9.1 Mechanical Complications

Recommendations for Mechanical Complications Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 C-EO 1 Patients with a mechanical complication of

ACS should be managed in a facility with cardiac surgical expertise.

2a B-NR 2 In patients with a mechanical complication of

ACS, short-term MCS devices are reasonable for hemodynamic stabilization as a bridge to surgery.1–3

Synopsis Timely reperfusion therapy has reduced the incidence of mechanical complications (ventricular septal rupture, mitral valve insufficiency due to papillary muscle infarction or rupture, or free wall rupture) after AMI (Figure 9).3,5 Although occasionally found incidentally, mechanical complications commonly present with recurrent or refractory chest pain or a new murmur accompanied by disproportionate HF, cardiogenic shock, or sudden cardiac death on clinical presentation within the first week after an AMI. Medical therapy alone is associated with high risk of early death6,7; definitive surgical correction is frequently the treatment of choice.8,9 Mortality rates with surgery are highest in subjects with cardiogenic shock and in those requiring early emergency/urgent intervention after AMI.10,11 Observed mortality rates following delayed surgery (>7 days) are lower but patient selection and survivor bias contribute to this observation.12,13 The availability of temporary MCS devices has led to increasing trends for delayed surgery due to concerns for the initial degree of extensive tissue destruction.14,15 Delayed surgical intervention may enable hemodynamic stabilization, lead to recovery of end-organ injury, and promote infarct tissue healing and maturation that could facilitate definitive repair. Percutaneous approaches toward repair have been used in patients with prohibitive surgical risk or contraindications to surgery as a primary or temporizing option in the setting of acute mitral regurgitation and ventricular septal rupture and remain an evolving area of investigation.16,17 Select patients with mechanical complications of ACS may be considered for cardiac transplantation or durable left ventricular assist device as a primary or bailout treatment strategy to improve survival.18

Recommendation-Specific Supportive Text

1 No RCTs evaluate the role of transfer of patients

with mechanical complications after MI to dedicated centers with cardiac surgical expertise. Although overall surgical mortality is approximately 40%, it remains the treatment strategy of choice. Hemodynamic deterioration is unpredictable and can be precipitous in previously stable subjects. Consequently, transfer to a Level 1 cardiac intensive care unit (CICU)19 with access to various temporary MCS devices and multidisciplinary experienced teams of surgical, interventional, HF, and palliative care specialists is recommended. Emerging data following the creation of shock teams supports the transfer of hemodynamically unstable patients from community hospitals to centers with multidisciplinary expertise.20,21 Although the exact timing remains uncertain, early corrective surgery is the treatment of choice for mechanical complications of MI.8,9,13 The risk of surgical correction is highest when performed in the setting of cardiogenic shock10,22,23 and appears lower when surgery is delayed. The early hazard with surgery is attributed to patient acuity, end-organ injury, and lack of tissue integrity to promote definitive and lasting repair. Selected subjects may be candidates for either definitive or temporizing percutaneous structural intervention as a bridge to definitive surgical intervention.16,17,24 Given the complexity of decision making, a Heart Team approach to guide feasibility, timing, and nature of corrective intervention as well as the need and selection of MCS support is recommended as soon as a mechanical complication is diagnosed. 2.	 No RCTs have evaluated the role of MCS in improv-

ing clinical outcomes in the setting of mechanical complications. The choice of specific MCS should be individualized and guided by patient characteristics, nature of the mechanical complication, and the hemodynamic profile. In patients with ventricular septal rupture, the use of an IABP has been shown to reduce left-to-right shunting and improve hemodynamics in patients with and without shock.25 Favorable hemodynamic effects with IABP are also noted with acute ischemic mitral regurgitation. Various devices have been utilized when IABP fails or if hemodynamic instability remains profound.1 The use of MCS devices has enhanced hemodynamic stabilization to allow the opportunity for consideration of delayed corrective strategy.14,15

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