Ventricular septal defect after percutaneous coronary intervention in acute myocardial infarction

Abstract

We present a report concerning two patients who developed a ventricular septal defect (VSD) complicating an acute myocardial infarction (MI) admitted to our intensive care unit last year. Clinical casesA 77-year-old, diabetic woman, without a prior history of hypertension and cardiac disease was admitted to our department for anterior acute MI about 6 h after the onset of symptoms. The ECG showed ST elevation in anterior leads. The Troponin I level was 88 ng/ml. She underwent emergency coronary arteriography, which showed three vessels disease. The culprit lesion was a sub-occlusive stenosis with thrombus in the mid-left anterior descending artery-a type B2 lesion, according to the AHA/ACC classification-with TIMI I distal flow. A primary angioplasty was performed with implantation of a TITAN 2 2.5 9 16 at 12 atm, after a pre-dilatation of the lesion with a balloon Fire Star 2 9 15 at 12 atm. The final result was TIMI II-III flow without any residual narrowing. Moreover, an eccentric 90%, focal stenosis of RCA and proximal stenosis of MO2, were detected.Echocardiogram showed an apical aneurysm and an ejection fraction of about 45%, without mitral insufficiency. Diastolic flow velocities were: peak E = 0.92 m/s, with a deceleration time of 260 ms and peak A = 1.07 m/s (E/A ratio = 0.90).The patient was treated with Aspirin, Clopidogrel, ACE inhibitors and Metoprolol.Six hours after PCI, Troponin I was decreased to 56 ng/ ml. Moreover, the ST elevations were reduced.After about 24 h, the patient suddenly complained of dyspnoea. The heart rate was 105 beats/min, blood pressure was 95/60 mmHg. Physical examination revealed tachypnoea, pulmonary rales and a 3/6 Levine holosystolic murmur on the left sternal border. She was also observed to be oliguric. The ECG again showed ST segment elevation in the anterior leads, and the Troponin I was 22 ng/ml.The beta blocker medication was discontinued, and inotropic agents (Dobutamine and Dopamine at 5-10 mcg/ Kg/m), oxygen and Furosemide were administered. Transthoracic echocardiography confirmed abnormalities of regional motion, furthermore the ejection fraction tended to increase to 50%. Evaluation of diastolic function revealed an inversion of E/A ratio ([1). In addition the right ventricle was mildly dilated, but the ratio of right/left ventricular diastolic diameters remained \2/3; right ventricular systolic function was preserved (tricuspid annular systolic motion = 25 mm).Colour-Doppler examination demonstrated a moderate left to right shunt through a small defect in the apical segment of interventricular septum (Fig. 1). In the absence of tricuspidal regurgitation, a pulmonary arterial pressure was not detectable.The patient was promptly transferred to cardiac surgery where an intra-aortic balloon pump (IABP) was first inserted, to allow further stabilization, and an emergency operation was then carried out. This included a coronary artery bypass graft to the RCA and concomitant surgical