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Ventricular Septal Rupture after Acute Myocardial Infarction : A Case Report Riki Hanafiah 1 ; Edwin Setiabudi 2 ; Triwedya Indra Dewi 3 ; Listiana Kosim 4 1 General Practitioner, Immanuel Hospital, Bandung, Indonesia 2,3 Cardiologist, Immanuel Hospital, Bandung, Indonesia 4 Anesthesiologist-Intensivist, Immanuel Hospital, Bandung, Indonesia References Case Illustration ❖ Blood Pressure : 85/54 mmHg ❖ Heart Rate : 100 bpm ❖ Respiratory Rate : 22x/min ❖ Temperature : 36.6°C ❖ SpO2 : 98% with Nasal Canulla 3 L/min ❖ Weight 70 kg, Height 168 cm, BMI 24,8 kg/m² ❖ Heart examination revealed cardiomegaly, normal heart sound without murmur ❑ A 65-year old female came to our ER, 3 hours after onset of chest pain ❑ No past history of hypertension or Diabetes Mellitus ❑ No family history risk, non smoker History of Present Illness Physical Examination ECG ▪ ST elevation in lead V1-V5, recriprocal in lead II, III and aVF ❖ Angiography : 90% stenosis in distal LCX & CTO in mid- LAD ❖ Using drug eluting stents 2.75 x 48 mm to the mid-LAD ❖ TIMI 3 flow, blood pressure after procedure : 80/55 mmHg with dopamine 10 mcg/kgBW/min IV infusion Primary PCI 1. Calvert PA, Cockburn J, Wynne D, Ludman P, Rana BS, Northridge D, et al. Percutaneous closure of postinfarction ventricular septal defect: in-hospital outcomes and long-term follow up of UK experience. Circulation. 2014 Jun; 129(23): 2395–402 2. Gray RJ, Sethna D, Matloff JM. The role of cardiac surgery in acute myocardial infarction with mechanical complications. Am Heart J 1983;106:723-8 3. Smyllie JH, Sutherland GR, Geuskens R, Dawkins K, Conway N, Roelandt J.. Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction. J Am Coll Cardiol 1990;15:1449–1455 4. Jones BM, Kapadia SR, Smedira NG et al. Ventricular septal rupture complicating acute myocardial infarction: a contemporary review. Eur Heart J 2014;35:2060–8. 10.1093/eurheartj/ehu248 Ventricular septal rupture (VSR) is a rare mechanical complication following acute myocardial infarction (AMI) Haemodinamic deterioration and cardiogenic shock is common VSR can develop from hours to weeks after AMI The mortality in patients with conservative treatment is as high as 80-90%, and the survival is less than 10% Introduction 24 hours after procedure, patient returned to ICU ➢ Deterioration of consciousness Head CT Scan → No infarct or ICH ➢ GCS E1M1V1 Intubate → Mechanical ventilator ➢ Physical Examination : BP : 93/56 mmHg Dobutamine 5-10 mcg/kgBW/min IV infusion Norepinephrine 0,1-1 mcg/kgBW/min IV infusion HR : 120-200 bpm, VT Cardioversion 100 Joule twice RR : 28x/min On Ventilator PSIMV Temp : 36.6°C SpO2 : 98% On Ventilator PSIMV Heart examination : irregular heart sound with 3/6 holosystolic murmur along the left sternal border; no crackles or sign of acute pulmonary edema Chest X-Ray ➢ Cardiomegaly, without pulmonary edema ECG after Primary PCI Echocardiography ❑ LVEF : hard to determine because of tachycardia, estimated between 30-40% ❑ Severe hypokinetic with aneurysm in mid to anterior apex ❑ VSR in anteroseptal wall, 6 mm, with left to right shunt ❑ No mitral regurgitation ❑ Moderate tricuspid regurgitation, high likelihood of pulmonary hipertension Laboratorium Creatinine eGFR 3.16 mg/dL 14.98 Acute Kidney Injury SGOT SGPT INR 264 IU/L 93 IU/L 1.36 Electrolytes Normal result Blood Gas Analysis Normal result Medication in ICU Dobutamin 5-10 mcg/kgBW/min IV infusion Noreepinephrine 0,1-1 mcg/kgBW/min IV infusion Amiodarone 300 mg for 24 hours IV infusion Was administered after cardioversion and stopped after 24 hours Enoxaparine 60 mg SC/12 hours Was stopped in 2 nd day because of stress ulcer Ceftriaxone 1 gr IV/24 hours Broad spectrum antibiotic for prophylaxis Pantoprazole 40 mg IV/12 hours Was administered in 2 nd day because of stress ulcer DAPT : Aspilet 80 mg/24 hours Clopidogrel 75 mg/24 hours Was stopped in 2 nd day because of stress ulcer Isosorbid dinitrate 5 mg/8 hours Vasodilator Bisoprolol 2.5 mg/12 hours Was administered in 2 nd day after amiodarone IV infusion was stopped Patient died 72 hours after admission to ICU, despite optimized mechanical and medical support Discussion ❖ In this case, stenosis of LAD and LCX resulted in AMI, and subsequently VSR occurred ❖ Immediate surgical repair or percutaneous closure are indicated in this patient, however, because of the limited facility and high risk to refer the patient to another hospital due to her haemodynamically unstable condition, we decided to optimize the conservative treatment Calvert PA, et al ❖ Advanced age and female sex were identified as risk factors for mortality in a long term follow up of VSR patients ❖ Cardiogenic shock in VSR patients has been associated with an increased risk of death Gray RJ, et al ❑ The mortality rate among patients with septal rupture who are treated conservatively without mechanical closure is approximately 24 % in the first 24 hours, 46 % at one week, and 67 to 82 % at two months Smyllie JH, et al ❑ The gold standard in the diagnosis of VSR is transthoracic echocardiography (TTE) ❑ TTE provide information about the size and location of the rupture, the ventricular function and the shunt significance and also help with the differential diagnosis in a patient presenting with cardiogenic shock Jones BM, et al ❑ Immediate surgical repair is indicated in the haemodynamically unstable patient ❑ Percutaneous closure may be considered if surgery is deemed to be too high risk or if the anatomy is amenable to device insertion. Conclusion ✓ High clinical suspicion and thorough physical examination can help identify VSR early ✓ VSR should be included in differential diagnosis of patients presenting with AMI and cardiogenic shock ✓ Since VSR complicating AMI has a high mortality, the early treatment of primary diseases and revascularization can prevent or reduce its occurrence.
