Myocardial infarction complicated by a large ventricular septal defect: a case report

    Authors

    Keywords

    myocardial infarction, ventricular septal defect, echocardiography

    DOI

    https://doi.org/10.15836/ccar2023.133

    Full Text

    Introduction : Ventricular septal defect (VSD) is severe but fortunately rare mechanical complication of myocardial infarction with high mortality: 30-40% ( 1 ), ranging up to 87% if associated with cardiogenic shock ( 2 ). It has been reported to occur more frequently in the anterior than inferior/lateral wall infarction (70% versus 29%), but inferior infarcts are associated with complex VSDs a worse prognosis. Therapeutic options include medical management, surgical and transcatheter repair with variable success ( 1 ). Case report : 58-year-old male patient, smoker with hypertension presented with signs and symptoms of heart failure lasting for 3 days. He did not have chest pain, but 12-lead electrocardiogram showed Q waves in inferior leads with clearly positive troponin (hs trponin I 578.5 ng/l). Physical examination corresponded to Killip class II and peculiar holosystolic precordial murmur was noted which prompted urgent bedside echocardiography. Left ventricle was mildly dilated with akinesia of basal and mid segments of inferoposterior wall. Ejection fraction was estimated 55%, there was mild mitral regurgitation and moderate secondary tricuspid regurgitation due to pulmonary hypertension. Atypical parasternal and subcostal projections revealed large VSD located in inferior part of septum (approximate diameter 3 cm) with massive left to right shunt. Patient was immediately transferred to clinical institution with cardiac surgery capacity. Angiography revealed two-vessel disease, including thrombotic subocclusion of right coronary artery mid segment. During angiography his status has worsened further with development of cardiogenic shock despite pharmacological and intraaortic balloon pump support so he underwent urgent operation. Large septal defect was reconstructed combining pericardium with pledgets and double bypass was created (VSM-LAD, RCA). After releasing aortic clamp and restoring circulation there was rupture of myocardial wall next to suture; repeated attempts to stabilize patient failed and he soon died of shock and the multiple organ failure ( Figure 1 ). A) Atypical parasternal projection showing large defect of basal inferoseptum. B) Massive turbulent left to right shunt. C) Remodeled left ventricle with inferior wall akinesia (A2C projection). D) Subcostal view of septal defect and corresponding shunt (E). F) CW Doppler of high velocity systolic flow through the defect. Conclusion : Mechanical complications of myocardial infarction are infrequently seen in the era of interventional cardiology (around 1/1000 STEMI patients) but bear significant morbidity and mortality despite early diagnosis. Urgent echocardiography is essential in acute coronary syndrome with signs of heart failure, especially if accompanied with new onset heart murmur.

    Cardiologia Croatica
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    Myocardial infarction complicated by a large ventricular septal defect: a case report

    Extended Abstract
    Issue5-6
    Published
    Pages133-134
    PDF via DOIhttps://doi.org/10.15836/ccar2023.133
    myocardial infarction
    ventricular septal defect
    echocardiography

    Authors

    Siniša Roginić*ORCIDGeneral Hospital Zabok and Hospital of Croatian Veterans, Zabok, Croatia
    Tereza KnaflecORCIDGeneral Hospital Zabok and Hospital of Croatian Veterans, Zabok, Croatia
    Vito MustapićORCIDMagdalena Clinic for Cardiovascular Diseases, Krapinske Toplice, Croatia
    Martina RoginićORCIDGeneral Hospital Zabok and Hospital of Croatian Veterans, Zabok, Croatia
    Mladen PredrijevacMagdalena Clinic for Cardiovascular Diseases, Krapinske Toplice, Croatia
    Krešimir ŠtambukORCIDMagdalena Clinic for Cardiovascular Diseases, Krapinske Toplice, Croatia
    Marija ČajkoORCIDGeneral Hospital Zabok and Hospital of Croatian Veterans, Zabok, Croatia
    Nikolina Mijač MikačićORCIDGeneral Hospital Zabok and Hospital of Croatian Veterans, Zabok, Croatia
    Domagoj FutivićORCIDGeneral Hospital Zabok and Hospital of Croatian Veterans, Zabok, Croatia

    Full Text

    Introduction : Ventricular septal defect (VSD) is severe but fortunately rare mechanical complication of myocardial infarction with high mortality: 30-40% ( 1 ), ranging up to 87% if associated with cardiogenic shock ( 2 ). It has been reported to occur more frequently in the anterior than inferior/lateral wall infarction (70% versus 29%), but inferior infarcts are associated with complex VSDs a worse prognosis. Therapeutic options include medical management, surgical and transcatheter repair with variable success ( 1 ). Case report : 58-year-old male patient, smoker with hypertension presented with signs and symptoms of heart failure lasting for 3 days. He did not have chest pain, but 12-lead electrocardiogram showed Q waves in inferior leads with clearly positive troponin (hs trponin I 578.5 ng/l). Physical examination corresponded to Killip class II and peculiar holosystolic precordial murmur was noted which prompted urgent bedside echocardiography. Left ventricle was mildly dilated with akinesia of basal and mid segments of inferoposterior wall. Ejection fraction was estimated 55%, there was mild mitral regurgitation and moderate secondary tricuspid regurgitation due to pulmonary hypertension. Atypical parasternal and subcostal projections revealed large VSD located in inferior part of septum (approximate diameter 3 cm) with massive left to right shunt. Patient was immediately transferred to clinical institution with cardiac surgery capacity. Angiography revealed two-vessel disease, including thrombotic subocclusion of right coronary artery mid segment. During angiography his status has worsened further with development of cardiogenic shock despite pharmacological and intraaortic balloon pump support so he underwent urgent operation. Large septal defect was reconstructed combining pericardium with pledgets and double bypass was created (VSM-LAD, RCA). After releasing aortic clamp and restoring circulation there was rupture of myocardial wall next to suture; repeated attempts to stabilize patient failed and he soon died of shock and the multiple organ failure ( Figure 1 ). A) Atypical parasternal projection showing large defect of basal inferoseptum. B) Massive turbulent left to right shunt. C) Remodeled left ventricle with inferior wall akinesia (A2C projection). D) Subcostal view of septal defect and corresponding shunt (E). F) CW Doppler of high velocity systolic flow through the defect. Conclusion : Mechanical complications of myocardial infarction are infrequently seen in the era of interventional cardiology (around 1/1000 STEMI patients) but bear significant morbidity and mortality despite early diagnosis. Urgent echocardiography is essential in acute coronary syndrome with signs of heart failure, especially if accompanied with new onset heart murmur.