Abstract 12100: Catastrophic Large Post-Stemi Inferoseptum Ventricular Septal Rupture With Left-to-Right Shunt and an Inferoseptum Pulsatile Pseudoaneurysm

Abstract

Case Presentation: 49-year-old male without known cardiovascular history presented with three days of atypical chest discomfort. 12-lead EKG revealed ST-segment elevations in II-III-aVF and depression in V1 suggestive of an acute infero-posterior MI (A), Troponin T at 6.85 ng/mL. Following administration of DAPT and heparinization, emergent coronary angiography proved a dominant RCA with proximal 60% and middle 100% occlusion (B), 80% focal stenosis at mid-LAD and 70% focal stenosis at prox-LCx (C). PCI with intra-aortic balloon pump support was performed, with two DES deployed in the RCA, use of a trans-venous pacemaker was required for complete AV block, and two defibrillations required for ventricular fibrillation. Following further hemodynamic compromise unexplained by his hemodynamic parameters, TEE was performed, demonstrating a large mid/distal infero-septum ventricular septal defect with left to right shunt (D, E and F), as well as a basal/mid infero-septum large pseudo-aneurysm (PSA) cavity (contained rupture) (G: low velocity Doppler flow from LV to PSA cavity, H and I show intact septum). The patient continued to decompensate requiring escalation to temporary mechanical circulatory support with VA-ECMO. Heart transplantation was initially considered, family decided to withdraw care due to multi-organ failure and poor prognosis Discussion: Due to widespread availability of primary percutaneous coronary intervention with early reperfusion, mechanical complications post MI are less common in current days. Following transmural MI, persistent hypotension and cardiogenic shock should alert for complications such as VSD or PSA. While VSD may be amenable to percutaneous or surgical closure, PSA is associated with very high mortality even if surgery is attempted. Given the presence of both a VSD and PSA, mechanical support with VA-ECMO allowed us to support the patient for several days as a bridge to decision regarding heart transplantation