Delayed ventricular septal rupture complicating acute inferior wall myocardial infarction

Abstract

Background: Ventricular septal rupture is a potentially fatal complication of acute myocardial infarction. Its incidence has declined with modern reperfusion therapy. In the era of percutaneous coronary interventions, it occurs a median of 18-24 hours after myocardial infarction and is most commonly associated with anterior myocardial infarction. We present a case of delayed ventricular septal rupture complicating acute inferior wall myocardial infarction.

Case presentation: A 53-year-old Caucasian male presented with epigastric pain for three days and electrocardiographic evidence for an acute inferior wall myocardial infarction. Coronary angiography revealed a total occlusion of the proximal right coronary artery. Reperfusion was achieved by balloon angioplasty followed by placement of a bare metal stent. On hospital day six, the patient developed acute respiratory distress, a new loud pansystolic murmur, and hemodynamic instability. Echocardiography revealed the presence of a large defect in the inferobasal interventricular septum with significant left-to-right shunt consistent with ventricular septal rupture. The patient underwent emergent surgical repair with a bovine pericardial patch.

Conclusion: Ventricular septal rupture after myocardial infarction should be suspected in the presence of new physical findings and hemodynamic compromise regardless of revascularization therapy.

Figure 1

Electrocardiogram. Initial ECG showing 2 mm coved ST segment elevation in the inferior leads with Q waves in leads III and aVF, consistent with acute inferior wall myocardial infarction.

Figure 2

Coronary angiogram.A) Left coronary system with diffuse disease. B) Thrombotic occlusion of the right coronary artery at the ostium. Note the absence of ipsilateral or contralateral collateral circulation. C) Following reperfusion, the right coronary artery shows marginal flow past the bifurcation due to distal embolization. The posterior descending and posterior lateral coronary arteries are faintly visible.

Figure 3

Echocardiogram.A) Transthoracic echocardiogram in the apical 4 chamber view showing a ventricular septal rupture in the inferobasal myocardial septum with left-to-right shunt by color Doppler mapping. B) Transthoracic echocardiogram in the parasternal long axis view showing significant right ventricular enlargement (proximal right ventricular outflow tract in this image) secondary to left-to-right shunt and volume overload. C) Transesophageal echocardiogram from a modified transgastric view at 0° demonstrates a 1.6 cm defect in the inferobasal septum at the level of the mitral valve (MV) and tricuspid valve (TV). D) High velocity turbulent flow of left-to-right shunt by color Doppler across the ventricular septal rupture noted in C.