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cardio.stemi.with-mechanical-complication.v1

STEMI complicated by mechanical complication (PMR / VSR / free-wall rupture)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E adjacent-disease overlay of cardio.stemi.core.v1 — STEMI complicated by mechanical complication (PMR, VSR, free-wall rupture / pseudoaneurysm). Inherits reperfusion + antiplatelet + statin + BB regimen from parent via routing; specializes for the catastrophic surgical-bridging phenotype with MCS support and emergent cardiothoracic repair. PMR typically posteromedial papillary in inferior MI (PDA single blood supply); VSR more common in septal/anterior MI; free-wall rupture risk peaks day 1-5 post-MI in elderly women with delayed reperfusion. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (overlay-specific differences documented inline in this dossier). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E recursive-depth wave 7 overlay.

Entry points (3)

  • symptom
    New harsh holosystolic murmur 2-7 d post-MI ± hemodynamic deterioration → PMR or VSR until proven otherwise
    new_harsh_holosystolic_murmur_post_mi
  • imaging
    STAT echo: acute severe MR (flail leaflet, eccentric jet, hyperdynamic LV) or VSR jet on color Doppler post-MI
    echo_acute_severe_mr_or_vsr_jet_post_mi
  • symptom
    Sudden hemodynamic collapse + new pericardial effusion 1-7 d post-MI → free-wall rupture / pseudoaneurysm / tamponade
    sudden_hemodynamic_collapse_with_effusion_post_mi

Required inputs (8)

  • agerequired
    demographic • used at CONTEXT
    Older age + female sex + late presentation = higher mechanical complication + surgical mortality (EuroSCORE-II)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension typical with mechanical complication; SCAI C-E staging drives MCS escalation
  • lactaterequired
    vital • used at RED_FLAGS
    Lactate ≥2 anchors SCAI C+ shock — mechanical complications almost always present in shock
  • echo_statrequired
    imaging • used at INITIAL_WORKUP
    STAT TTE/TEE confirms PMR (flail leaflet, eccentric jet), VSR (jet across septum on color Doppler), or free-wall rupture (effusion + tamponade physiology)
  • right_heart_cath_for_oxygen_step_up
    imaging • used at BRANCHING_WORKUP
    O2 step-up ≥7% from RA→RV = VSR; PA cath also quantifies hemodynamic compromise + guides MCS choice
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Confirms infarct context; trajectory informs reperfusion success
  • creatininerequired
    lab • used at CONTEXT
    eGFR for contrast + dosing; CKD interacts with surgical risk per EuroSCORE-II
  • cor_angiorequired
    imaging • used at TREATMENT
    Culprit confirmation; complete coronary anatomy required for CABG planning if surgery indicated

12-phase flow (10)

  1. 1FRAME
    Mechanical complication of STEMI (PMR / VSR / free-wall rupture) — catastrophic; surgical repair is Class I; medical management alone has >50% mortality for VSR + >80% for free-wall rupture
    inputs: echo_stat
    advance: mechanical complication confirmed on echo
  2. 2ENTRY
    STAT echo + cardiothoracic surgery activation + cath lab activation simultaneously; MCS team alerted; ICU bed
    inputs: age, sbp, lactate
    advance: CT surgery + cath + MCS + ICU activated in parallel
  3. 3CONTEXT
    Allergies, antithrombotic load already received (PCI status), bleed risk, frailty, comorbidities → EuroSCORE-II
    inputs: sbp, creatinine
    advance: surgical-risk-adjusted decision documented
  4. 4RED_FLAGS
    Cardiogenic shock (almost universal with mechanical complication); free-wall rupture with tamponade physiology = STAT pericardiocentesis bridge to OR; biventricular failure → VA-ECMO
    inputs: sbp, lactate
    actions: cardiogenic_shock, acute_valvular_emergency
    advance: shock + tamponade screening complete; MCS plan documented
  5. 5INITIAL_WORKUP
    STAT TTE → TEE if TTE non-diagnostic; ECG + troponin + BMP + lactate + CBC + type & cross 4-6 units; CXR for pulmonary edema severity
    inputs: echo_stat, troponin, creatinine
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: mechanism + severity documented
  6. 6BRANCHING_WORKUP
    PMR: confirm flail leaflet (typically posteromedial papillary in inferior MI from PDA territory); VSR: O2 step-up RA→RV at right heart cath OR direct visualization on TEE/echo; free-wall rupture: pericardial effusion + tamponade physiology
    inputs: cor_angio
    actions: acute_valvular_emergency
    advance: mechanism characterized + surgical plan finalized
  7. 7TREATMENT
    EMERGENT surgical repair (Class I per ACC/AHA 2025 ACS); MCS BRIDGE while awaiting OR (IABP first-line for VSR/PMR per ESC 2023; Impella CP per DanGer Shock; VA-ECMO if biventricular failure or RV dysfunction); afterload reduction with nitroprusside if SBP permits (acute MR); avoid ACEi/ARB acutely if shock
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: MCS bridging + surgical repair scheduled (target <6 h for free-wall rupture, <24 h for PMR/VSR if hemodynamics permit)
  8. 8DISPOSITION
    Cardiac surgical ICU post-op (or CICU if non-operative); long ICU stay typical
    advance: unit assigned + post-op MCS weaning plan documented
  9. 9MONITORING
    Post-op telemetry + arterial line + PA cath consideration; serial echo for repair integrity; vigilance for residual VSR/MR; antibiotics for prosthetic valve if implanted; anticoagulation per surgical type
    inputs: echo_stat
    actions: panel.cardiac
    advance: repair integrity confirmed + MCS weaned + GDMT initiated
  10. 10FOLLOWUP
    Cardiology + cardiac surgery follow-up; echo at 30-90 d for repair durability + LVEF reassessment; ICD eligibility per MADIT-II if EF <30; cardiac rehab
    advance: cardiac rehab booked + ICD pathway documented