LARGE VENTRICULAR SEPTAL DEFECT CAUSED BY AN ACUTE INFERIOR ST ELEVATION MYOCARDIAL INFARCTION

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Septal rupture is an uncommon, but fatal, complication of myocardial infarction (MI) which usually occurs 3-5 days after an acute MI, however, in rare instances it may develop within the first 24 hours or as late as 2 weeks. It is associated with a tremendously high mortality rate (41-80%) which has been unchanged during the last few decades [1]. We hereby report one such rare instance when this complication occurred within 48 hours following MI. CASE PRESENTATION: A 59 year old male with a history of coronary artery disease status post percutaneous coronary intervention in 2011 presented to the emergency room with chest pain for 1 hour prior to admission. Initial electrocardiogram showed acute inferior ST elevation MI. Emergent cardiac catheterization showed occlusion of the right coronary artery and a drug eluting stent was placed. The patient was transferred to intensive care unit for close monitoring, however, 5 hours later he developed sudden increasing shortness of breath. Physical examination revealed a new systolic murmur and an echocardiogram was performed showing a large ventricular septal defect (VSD) (Image-1). Overnight he developed atrial fibrillation and became hemodynamically unstable with a systolic blood pressure in the 60's. He was then cardioverted without success and amiodarone was bolused followed by a continuous infusion. The decision was made for emergent coronary artery bypass grafting and repair of the VSD the next day. The defect was successfully closed with a Dacron patch after timely and prompt correction of atrial fibrillation. DISCUSSION: There are 3 life threatening complications of acute MI which include rupture of the left ventricular free wall, rupture of the interventricular septum and development of severe mitral regurgitation. One study compared 225 patients who had a first MI and experienced one of the mechanical complications to 1012 patients without complications to analyze the reason behind these complications. They reported that delayed hospitalization (>24hours), excessive in-hospital physical activity and recurrent ischemia as some of the risk factors for rupture [2]. Early retrospective studies noted lower mortality rates in patients undergoing surgical repair > 6 weeks after infarction than those who went in earlier, however these studies had selection bias as patients with normal ejection fraction and smaller defects survived to become low risk surgical candidates [3]. Hence, optimal approach varies with the clinical presentation. In patients like ours who develop cardiogenic shock, death is inevitable without urgent surgical intervention. CONCLUSIONS: This case is an unusual scenario where this fatal complication occurred within 48 hours following MI even after prompt revascularization. It is unique because it was further complicated with atrial fibrillation, which can further reduce survival probability, yet he survived and defied the odds. Reference #1: Saplaouras A1, Sakellaropoulou A1, Mililis P1, Bazoukis G1, Kolokathis AM1, Konstantinidou E1, Anagnostou A1, Panagopoulou N1, Vlachos K1, Lakoumentas I1, Sideris A1. Ventricular septal rupture following myocardial infarction: A potentially fatal complication. Clin Case Rep. 2019 Jan 9;7(2):397-400 Reference #2: Figueras J, Cortadellas J, Calvo F, Soler-Soler J. Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction: study in 225 patients with free wall, septal or papillary muscle rupture. J Am Coll Cardiol 1998; 32:135. Reference #3: Daggett WM, Guyton RA, Mundth ED, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977; 186:260 DISCLOSURES: No relevant relationships by John Mikhail, source=Web Response No relevant relationships by Mohammed Shariff, source=Web Response