Introduction: Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). As acute reperfusion strategies for AMI have evolved, VSR has become increasingly rare and is identified earlier in the post-MI course. Despite significant improvements over the last two decades in overall mortality for patients with AMI, the outcome of patients who develop VSR remains poor. We present a case of ventricular septal rupture complicating acute myocardial infarction.
Case Presentation: A 49-year-old Cambodian, smoker, alcoholic, non-diabetic, hypertensive farmer presented with acute dyspnea after ten days acute myocardial infraction on medical therapy at a hospital in Cambodia. His blood pressure was 109/77 mm Hg, Pulse 113bpm, spO2 99% (air room). Cardiac auscultation revealed a harsh holosystolic murmur, which was heard over the entire precordium. Bibasilar crackles of the lungs.
Results: high sensivity Troponin T 167.9ng/L (<14ng/L), NT-proBNP 3568pg/ml (<125pg/ml). Electrocardiogarphy showed rapid sinus rhythm with ST elevation and T wave inversion in inferior wall. Chest X-ray: PA views showed increase in pulmonary blood flow, cardiac shadow was within normal limits. Left larger than right pleural effusion.Transthoracic echocardiography revealed a left ventricle (LV) with overall preserved systolic function and inferior hypokinesis, a dilated right ventricle, pulmonary hypertension with PAPs 55mmHg and a large, sharply demarcated interventricular septal defect with a large, turbulent left-to-right transseptal flow.
Discussion: the diagnosis is made by a prompt transthoracic echocardiogram identifying drop-out of the ventricular septum in the 2D image and demonstration of flow across the septum using colour Doppler. Evidence of right-ventricular dilation and pulmonary hypertension are also important clues to the diagnosis. The remaining portions of the left ventricle are often hyperdynamic unless there is a large territory of infarction, or previous ischaemic insults have led to compromised function. Colour Doppler evaluation can also be useful to assess the anatomical size of the defect.
Conclusion: Rupture of the interventricular septum is an uncommon complication of MI. VSR occurs in a zone of necrotic myocardial tissue, usually within the first 10-14 days. A high index of suspicion is a loud systolic murmur is heard, usually within the first week after an acute myocardial infarction coincident with the onset of the murmur, the patient’s clinical course undergoes a sudden deterioration, with the development of congestive heart failure and, often, cardiogenic shock. Diagnosis is confirmed with the aid of echocardiography and the presence of a left-to-right shunt