Ventricular septal rupture following acute myocardial infarction - a rare complication

Abstract

Ventricular septal rupture (VSR) after acute myocardial infarction with the consequence of hemodynamic unstability is a rare complication and it's an medical emergency. Mortality of these group patients is higher than 90% to 95% without a rapid diagnosis and correction by surgical intervention.Spontaneous closure of VSR is extremely rare. We report the case of a patient with acute myocardial infarction with ventricular septal rupture (VSR) with cardiogenic shock that was diagnosed in our modern coronary care unit by the bed side portable echocardiographic machine (vivid).The incidence of ventricular septal rupture (VSR) after acute myocardial infarction is extremely rare in this reperfusion era.This condition is associated with a high mortality rate, even after the cardiac surgery . Our case emphasizes the risk factors and evolution of this condition.A 36 years old young hypertensive young man was admitted on 8 th August,2014 through the emergency department of university cardiac centre for central chest pain ,dyspnea, nausea and bilateral shoulder pain for the last last 7-8 days. He consulted with his family physician for the same complaints and later he was referred to get admission in our hospital. The patient's condition was detoriating gradually. Physical examination revealed a regular pulse of 110 beats/min. The blood pressure was 100/70 mmHg and there was a systolic murmur best heard at the apex, radiating to the axilla. . Pulmonary rales were present and there was no peripheral edema, hepatomegaly and raised JVP.The 12-lead electrocardiogram Figure 1) showed sinus rhythm at 125 beats/ min, low voltage QRS complex voltage in the limb leads, q waves in II,III, AvF and a 4 mm ST elevation in the anterior leads (V 2-4 ).Serum troponin T level at admission was 1.75 ng/ml, CK-MB 28 , Serun creatinine 1.25, Serum electrolytes are within normal limit.He was managed as a case of acute antero-septal MI with old inferior MI and on the following day after his admission he developed cardiogenic shock , examination reveals pulse was 115 beats/min and blood pressure was 80/40 mm of Hg.Then we put the patient under ionotrophic support ,transthoracic echocardiography was done and (figure 2,3 & 4) revealed a small rupture of the apical ventricular septum (figure 2) causing a VSR with left-to-right shunt (figure 3) and Doppler study showed the pressure gradient

Case of ventricular septal rupture following acute myocardial infarction

“…VSRs are a rare complication post-MI and in most cases are fatal without intervention. 4 Risk factors for the development of a VSR include advanced age (>65 years), female sex, chronic renal disease and the absence of previous MIs. 1 Septal rupture occurs more frequently with anterior MIs.…”

“…VSRs can result in volume overload of the RV, subsequent volume overload of the LV which increases the risk of deterioration to haemodynamic instability and death due to pump failure. 3,4…”