Post infarction ventricle septal rupture: it is not always a lethal condition.

Author : N.E. Damaiati, R. A. Sukaton, H. Isnanijah
Upload Date : 19-04-2018

Introduction: Ventricular septal rupture (VSR) is one of the serious complications following myocardial infarction. The incidence is rare yet its mortality rate is quite high (up to 80%). Independent risk factors include elderly, female, prior stroke, chronic kidney disease (CKD), and congestive heart failure (CHF). In addition, those who are presented with ST segment elevation and initial positive cardiac biomarkers, tend to develop VSR more. Majority cases showed symptomatic manifestation such as altered hemodynamics. This study presents a rare case of asymptomatic presentation of VSR after myocardial infarction.

Case Description: A 59-year-old female came to the outpatient clinic for a routine control. She had a history of anterior acute ST elevation myocardial infarction (STEMI) 4 years ago without any history of revascularization therapy. Currently none of symptoms were presented. The patient was hemodinamically stable. Auscultation revealed pansystolic murmur.

During transthoracal echocardiograph examination, intraventricular septal rupture with a left to right shunt muscular ventral septal defect (VSD) was suspected. Other findings included low systolic ejection fraction (EF 40%) and akinetic basal mid anteroseptal, anterior, and apicoanteroseptal wall. Coronary angiogram showed two vessel disease (left anterior descending (LAD) and right coronary (RCA) artery) and an aneurysm in LAD. The patient was then refered to Harapan Kita National Heart Center for surgical repair.

Discussion and Conclusion: The incidence of VSR complicating myocardial infarction has been declined following the emergence of reperfusion strategies, from 1 – 2 % to 0.17 – 0.31%. However, the mortality rate among such patients remains high.  

VSR is classified into three based on its pathophysiology, the latter type shows concomitant aneurysm formation with thinning of the septum, hence results in subsequent rupture. This mechanism, which correlates with older infarcts, might be similar to the case.

Definitive surgery remains the first line treatment for VSR following MI, however those with a challenging operation might lead to high early mortality, as such surgery has the highest mortality rate among any cardiac surgery. Nevertheless, not having any repair surgery has certainly even higher mortality rate due to further deterioration. Eventually, the management strategy of each patient should be determined according to its risk and benefit.

KEYWORDS : Ventricular septal rupture, myocardial infarction, post infarction ventricular septal rupture, asymptomatic ventricular septal rupture

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