Ventricular septal rupture following MI: A potentially fatal
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The present case has been reported in the journal Clinical Case Reports. A 73‐year‐old man with medical history of hypertension and diabetes mellitus presented to the emergency department of our hospital complaining of fatigue and dizziness. He reported having an episode of epigastric pain of two‐hour duration a week ago.

His vital signs on admission were as follows: blood pressure 110/70 mm Hg, heart rate 52 beats per minute, and SpO2 98%. Cardiac and pulmonary auscultation were unremarkable. Electrocardiogram revealed sinus rhythm with intermittent second‐degree atrioventricular block (2:1), and Q‐waves in the inferior lead with ST‐segment elevation >2 mm (Figure 1). On admission, levels of hs‐Troponin T were elevated (2657 μg/L) as well as the rest of myocardial injury markers.

Transthoracic echocardiogram (TTE) showed reduced left ventricular ejection fraction, estimated about 35%‐40%, with inferior wall akinesis. The patient underwent coronary angiography the next day, which revealed triple vessel disease. The left anterior descending artery had two 80% stenoses in the proximal and mid‐segments.

The left circumflex artery had a 70% proximal stenosis and an 80% stenosis in the mid portion. In addition, the right coronary artery had subtotal occlusion at the mid‐segment (Figure 2). The heart team recommended coronary artery bypass grafting surgery, so the patient was admitted to the intensive care unit with the diagnosis of subacute inferior myocardial infarction.

He remained asymptomatic and hemodynamically stable during the first two days of hospitalization, with myocardial damage enzymes following a downward trend. On the third day, he developed acute dyspnea accompanied by hemodynamic instability. The patient was initiated on inotropic agents.

Cardiac auscultation revealed a holosystolic murmur that was absent the days before and that was most clearly heard in the left lower sternal border. TTE did not reveal acute mitral regurgitation or left‐to‐right shunt despite the high clinical suspicion of a mechanical complication. The patient immediately underwent right‐side catheterization which supported the diagnosis of VSR.

A repeat TTE revealed the communication between right and left ventricle with color Doppler, possibly due to the progression of the septal rupture. Despite high doses of inotropic agents and optimal medical therapy, the patient remained hemodynamically unstable. An emergent surgical repair was decided by the cardiothoracic team. During the preparation of intra‐aortic balloon pump insertion, the patient suffered a cardiac arrest.

After the second cycle of cardiopulmonary, resuscitation return of spontaneous circulation was detected and the intra‐aortic balloon pump was positioned. The patient suffered a second cardiac arrest and died despite the resuscitation attempt, before undergoing surgery.

Key clinical message:-
- Mechanical complications of acute myocardial infarction include ventricular septal rupture (VSR), free wall rupture, and ischemic mitral regurgitation.

- Postinfarction VSR is a rare but serious complication of myocardial infarction. VSR has a lower incidence in the era of new reperfusion therapies.

- However, clinicians should be aware of this potentially fatal complication as the mortality remains extremely high. Early diagnosis and treatment are the cornerstones of achieving a better outcome.

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