INFERIOR WALL INFARCT COMPLICATED BY POST-INFARCTION VENTRICULAR SEPTAL DEFECT

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Ventricular septal defect (VSD) is a rare but devastating complication seen following septal myocardial infarction (MI). Despite decrease in incidence with implementation of early reperfusion strategies, mortality remains high. Clinical recognition and subsequent repair are critical for optimizing patient outcomes. We present a case of post-infarction VSD diagnosed on transthoracic echocardiography (TTE) CASE PRESENTATION: An 89-year-old male with known history of coronary artery disease and prior percutaneous intervention involving the right coronary artery presented with chest pain. Electrocardiogram showed ST segment elevations in the inferior leads concerning for an acute MI (Figure 1). He was taken for emergent cardiac catheterization which revealed multivessel disease and a culprit thrombotic distal right coronary artery lesion. a 2.75 mm drug-eluting stent was deployed in an overlapping fashion over the prior stent. On hospital day 5, the patient experienced sudden onset shortness of breath with new holosystolic murmur on cardiac auscultation. TTE suggested a newly formed VSD. Transesophageal echocardiogram confirmed a 2.4 cm x 1.8 cm inter-ventricular septal defect with heavy turbulent flow (Figure 2). Maximal opening was 0.7 cm on the RV side with a true channel on the LV side measuring 1.4 cm in width. He remained hemodynamically stable and was transferred to the intensive care unit for optimization of volume status. Patient was eventually transferred to a tertiary center for percutaneous repair DISCUSSION: VSD is a life-threatening mechanical complication seen following transmural MI. The defect can occur at various parts of the interventricular septum, thus can be seen with both anterior and inferior wall MI. Incidence is rare with emergent coronary revascularization with incidence estimated between 0.17-0.31%. However, clinical recognition is essential as mortality nears 100% without intervention. Patients are typically hemodynamically stable initially, although can rapidly deteriorate into cardiogenic shock. Detection of new holosystolic murmur should prompt urgent evaluation with echocardiogram. The cornerstone of management is mechanical repair, although early surgical intervention has not shown benefit due to inability of friable myocardium to hold sutures. Mainstay of medical therapy includes achieving euvolemia and adequate cardiac output with inotropic support. Percutaneous repair can serve as a bridge to definitive surgical intervention. Procedures should ideally be performed in high volume centers due to high rate of operative complications CONCLUSIONS: post-MI VSD is a serious but rare complication of transmural septal MI with mortality 30 days mortality as high as 96%. The complicated management strategy requires a delicate balance between medical therapy and surgical repair. Early recognition of post-MI VSD is essential in medical decision making and management Reference #1: Goyal, A. and Menon, V., 2020. Contemporary Management Of Post-MI Ventricular Septal Rupture - American College Of Cardiology. [online] American College of Cardiology. Available at: [Accessed 10 April 2020]. Reference #2: Suder B, Janik Ł, Wasilewski G, et al. Post-myocardial infarction ventricular septal defect. Is it better to operate on a fresh infarction or to wait? A case study. Kardiochir Torakochirurgia Pol. 2016;13(1):39–41. doi:10.5114/kitp.2016.58963 Reference #3: Marek A. Deja, Jacek Szostek, Kazimierz Widenka, Bartlomiej Szafron, Tomasz J. Spyt, Mark St.J. Hickey, Andrzej W. Sosnowski, Post infarction ventricular septal defect – can we do better?, European Journal of Cardio-Thoracic Surgery, Volume 18, Issue 2, August 2000, Pages 194–201, DISCLOSURES: No relevant relationships by Nami Moradi, source=Web Response No relevant relationships by Shawnt Tosonian, source=Web Response