Case Report: Two-patch technique with BioGlue salvages a patient with acute inferior wall myocardial infarction complicated by ventricular septal rupture and cardiogenic shock

Abstract

Post-myocardial infarction ventricular septal rupture (VSR) is a rare but often fatal complication of acute myocardial infarction (AMI). Without surgical or percutaneous intervention, mortality is exceedingly high. Even with corrective procedures such as surgical repair or transcatheter septal closure, in-hospital mortality remains substantial, particularly in hemodynamically unstable patients. We report a case of acute inferior-posterior wall ST-segment elevation myocardial infarction complicated by a large VSR and cardiogenic shock. Immediate venoarterial extracorporeal membrane oxygenation support was initiated. The patient subsequently underwent surgical repair using a modified infarct exclusion technique, in which BioGlue was applied between two patches to reinforce closure, and the second patch was extended into the ventriculotomy to simplify the procedure. The patient survived and remained free of recurrent VSR at the 5-month follow-up. This modified approach offers a feasible and effective strategy for managing acute inferior-posterior VSR following AMI, particularly in critically ill patients.

Keywords: acute myocardial infarction; cardiac surgery; cardiogenic shock; post-infarction ventricular septal rupture; ventricular septal rupture.

Figure 1

Electrocardiography, chest radiography, and transthoracic echocardiography findings. (A) Twelve-lead electrocardiogram showing supraventricular tachycardia 130 bpm; incomplete right bundle branch block (ICRBBB); ST-segment elevation in leads I, II, and aVF (suspected reversed arm leads); and ST-segment depression in V2–6. (B) Chest radiograph demonstrating right ventricular enlargement and pulmonary arterial plethora. (C,D) Apical four-chamber views. (E,F) Modified apical four-chamber views with two-dimensional and color Doppler imaging, revealing a large rupture of the inferior–posterior interventricular septum (arrows) with a significant left-to-right shunt. LV, left ventricle; RV, right ventricle; VSR, ventricular septal rupture.

Figure 2

Coronary and left ventricular angiography. (A,B) Left anterior oblique (LAO) view with cranial angulation demonstrating total occlusion of the middle right coronary artery (red arrow) and subsequent bare-metal stent deployment (yellow arrow). (C,D) Right anterior oblique (RAO) and LAO views during diastole. (E,F) RAO and LAO views during systole, illustrating rupture of the inferior and posterior interventricular septum with a substantial left-to-right ventricular shunt (arrows). LV, left ventricle; RV, right ventricle; VSR, ventricular septal rupture.

Figure 3

Operative findings and procedures. (A) Medium sternotomy with posterior left ventriculotomy along the septal margin, revealing extensive infarction of the inferior wall (arrow) and a large tear of the posterior–inferior basal septum measuring 1.5 cm × 6 cm. (B) Placement of the first bovine pericardial patch using continuous 4-0 Prolene suture (arrows). (C) Application of a second patch composed of two layers of bovine pericardium combined with a 32 mm J graft, employing the infarct exclusion technique, with BioGlue applied between the two layers (arrows). (D)) Closure of the ventriculotomy with additional applied BioGlue reinforcement (arrow). (E) Schematic illustration of the novel operative technique.