Ventricular septal rupture: A rare post-myocardial infarction complication with a very high mortality rate

Abstract

A 69-year-old diabetic and hypertensive man with no prior cardiovascular history was admitted to the emergency department complaining of dizziness and extreme fatigue. He had noticed worsening dyspnea for a few days without chest pain. The electrocardiogram showed deep Q waves with persistent ST-segment elevation in the anterior leads (Fig. 1a). Physical examination revealed a pansystolic murmur and systemic hypoperfusion signs including skin pallor and cold extremities and vital signs showed hypotension (85/66), sinus tachycardia (120 bpm) and low oxygen saturation (83% with ambient air). Troponine I (62 ug/L, n < 0.09 ug/L), creatine kinase (1447 U/L, n < 222 U/L) and LDH (2838 U/L, n < 240) were concordant with a sub-acute presentation. A transthoracic echocardiography (TTE) confirmed the suspicion of an extensive antero-septo-apical akinesia with an apical aneurysm and a severly impaired left ventricular ejection fraction (35%). The TTE also revealed a left-toright shunt (maximal systolic gradient of 28 mmHg) at the apex due to a 7 mm diameter ventricular septum rupture (VSR) (Fig. 1b). On the basis of these findings, we concluded to cardiogenic shock in the context of a VSR complicating a sub-acute anterior myocardial infarction (MI). An emergency coronary angiography revealed total occlusion of the mid left anterior descending coronary artery (LAD) (Fig. 1c) with no collateral flow. No revascularization was attempted since no significant benefit was