A Complication of Acute Myocardial Infarction

Dewaswala and Chait. HCA Healthcare Journal of Medicine (2020) 1:3 https://doi.org/10.36518/2689-0216.1054

Clinical Image

Nakeya Dewaswala, MD,1, 2 Robert Dean Chait, MD, FACP, FACC1, 2 Author affiliations are listed at the end of this article. Abstract Correspondence to: Description Robert Chait, MD, FACP, Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (MI). The case presents an apical four chamber echocardiogram showing mid-septal discontinu- FACC ity with lateral to medial movement of the transected ventricular septum during systole University of Miami /JFK and diastole. Color Doppler demonstrates flow across the septum with extensive anatomic Medical Center destruction of the ventricular septum. Palm Beach Regional GME Keywords Consortium myocardial infarction/complications; ventricular septal rupture; echocardiography; ventricu- 5301 South Congress Ave lar septal rupture/therapy; cardiovascular diseases; heart rupture, post-infarction Atlantis, FL 33462 ([email protected]) Case Presentation Discussion A 54-year-old male presented 24 hours after Ventricular septal rupture (VSR) is a rare com- he developed sub-sternal chest pain. Physical plication after acute myocardial infarction (MI). examination was unremarkable and did not reveal a murmur. EKG showed ST elevation in The incidence of VSR has decreased from the anterolateral leads. Echocardiogram was 1-3% following ST-segment elevation MI in the diagnostic of ventricular septal rupture. Apical pre-reperfusion era to 0.17-0.31% following pri- four chamber view showed mid-septal discon- mary percutaneous coronary intervention.1 tinuity with lateral to medial movement of the transected ventricular septum during systole Transmural infarction due to the complete and diastole. (Video 1) Color Doppler demon- occlusion of any coronary vessel subtending a strated flow across the septum with extensive portion of the septum can result in VSR.2 anatomic destruction of the ventricular septum. (Video 2) Patients with VSR often present with

Video 1. Apical four chamber echocardiogram showed mid-septal discontinuity with lateral to medial movement of the transected ventricular septum during systole and diastole. Click on the image to download the video.

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Video 2. Color Doppler demonstrated flow across the septum with extensive anatomic destruction of the ventricular septum. Click on the image to download the video. hemodynamic instability or frank cardiogenic 3 References shock. 1. Jones BM, Kapadia SR, Smedira NG, et al. Ventricular septal rupture complicating acute The diagnosis is made by a prompt transtho- myocardial infarction: a contemporary review. racic echocardiogram identifying drop-out of Eur Heart J. 2014;35(31):2060‐2068. https://doi. the ventricular septum in the 2D image and org/10.1093/eurheartj/ehu248 demonstration of flow across the septum using 2. Crenshaw BS, Granger CB, Birnbaum Y, et al. color Doppler.1 If necessary, a pulmonary cath- Risk factors, angiographic patterns, and out- eter can be placed at bedside. The detection comes in patients with ventricular septal defect of a step up in the O2 saturation in the right complicating acute myocardial infarction. GUS- TO-I (Global Utilization of Streptokinase and ventricle or pulmonary artery will confirm the 4 TPA for Occluded Coronary Arteries) Trial Inves- diagnosis. tigators. Circulation. 2000;101(1):27‐32. https:// doi.org/10.1161/01.CIR.101.1.27 Surgical closure is the definitive treatment 3. Menon V, Webb JG, Hillis LD, et al. Outcome for post-infarction VSR. Transcatheter septal and profile of ventricular septal rupture with closure using occlusion devices can also be at- cardiogenic shock after myocardial infarction: a tempted in inoperable patients but the necrot- report from the SHOCK Trial Registry. Sould we ic tissue makes successful closure challenging.5 emergently revascularize occluded coronaries in Mortality of VSR in the setting of cardiogenic cardiogenic shocK?. J Am Coll Cardiol. 2000;36(3 shock is high.3, 6 Suppl A):1110‐1116. https://doi.org/10.1016/S0735- 1097(00)00878-0 Conflicts of Interest 4. Teo WS, Tong MC, Quek SS, Tan AT, Ong The authors declare they have no conflicts of KK. Ventricular septal rupture in acute myocardial infarction. . interest. Ann Acad Med Singapore 1990;19(1):15‐22. Drs. Dewaswala and Chait are employees of 5. Schlotter F, de Waha S, Eitel I, Desch S, Fuer- nau G, Thiele H. Interventional post-myocardial JFK Medical Center, a hospital affiliated with infarction ventricular septal defect closure: the journal’s publisher. a systematic review of current evidence. Eu- . 2016;12(1):94‐102. https://doi. This research was supported (in whole or in roIntervention org/10.4244/EIJV12I1A17 part) by HCA Healthcare and/or an 6. Thiele H, Kaulfersch C, Daehnert I, et al. Imme- HCA Healthcare affiliated entity. The views diate primary transcatheter closure of postin- expressed in this publication represent those of farction ventricular septal defects. Eur Heart the author(s) and do not necessarily represent J. 2009;30(1):81‐88. https://doi.org/10.1093/eu- the official views of HCA Healthcare or any of rheartj/ehn524 its affiliated entities. Author Affiliations 1. University of Miami School of Medicine 2. JFK Medical Center, Miami, FL

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