Percutaneous closure of ventricular septal rupture after myocardial infarction: a case report of competing timelines in multifactorial shock

Ventricular septal rupture (VSR) following acute myocardial infarction is a rare but deadly complication with mortality rates exceeding 90% when left untreated. Coronary ischaemia leads to myocardial necrosis and friability resulting in septal rupture, most commonly 3–5 days post-infarction. The sudden development of a left-to-right shunt causes volume overload in the right ventricle, pulmonary vasculature, and left atrium, precipitating biventricular failure, and cardiogenic shock. Management requires careful consideration of timing and modality of closure along with stabilization with mechanical circulatory support in severe cases.

A 65-year-old female presented with anterior ST-segment elevation myocardial infarction complicated by VSR diagnosed the same day, cardiogenic shock, and progressive multiorgan dysfunction. Following intra-aortic balloon pump (IABP) placement and percutaneous coronary intervention to the left anterior descending artery, she experienced ventilator-associated pneumonia, ventricular fibrillation arrest, and acute renal failure requiring continuous renal replacement therapy. Despite inotropic support and IABP, the patient remained in cardiogenic shock. Given her persistent haemodynamic instability, the decision was made to proceed with delayed percutaneous VSR repair. On hospital day 11, she underwent percutaneous VSR closure with a 24-mm Amplatzer occluder device, resulting in immediate haemodynamic improvement leading to successful IABP removal. In spite of VSR repair, the patient's pulmonary sepsis worsened precipitating left ventricular dysfunction requiring Impella CP placement. Despite mechanical circulatory support, multiorgan failure ensued and the patient ultimately expired.

This case highlights the challenges of managing post-infarct VSR with delayed percutaneous device closure in the setting of mixed cardiogenic and septic shock.