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Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a rare condition that carries significant morbidity and mortality. It occurs as a complication of myocardial infarction affecting the interventricular septum. The introduction of thrombolytic therapy has reduced its incidence.


Presentation

Ventricular septal rupture (VSR) commonly occurs as a result of myocardial infarction (MI). VSR is a rare condition that occurs in 0.3% of individuals who have suffered MI, and it carries high morbidity and mortality [1]. Although the introduction of thrombolytic therapy has resulted in the reduction of VSR incidence, cases still occur [2] [3]. Risk factors include advanced age, female sex, chronic renal diseases, and cardiovascular diseases [4] [5].

Typically VSR may present as worsening of a patient's condition after recent MI, following a short period of clinical stability and usually with complaints of chest pain and dyspnea [6]. Mitral valve regurgitation (MVR) may present in a similar way as VSR and is thus one of the main differential diagnoses, notwithstanding that MVR complicates one in five cases of VSR. Upon examination, a significant percentage of patients have a loud holosystolic murmur, most prominent in the left sternal border, which may radiate to several areas in the chest. In addition, there is commonly a parasternal thrill. Murmurs produced by both VSR and MVR may radiate to the axilla, however, an MVR murmur is usually loudest at the apex and can be heard during diastole.

Further complications of VSR that may ensue are low cardiac output, which in turn leads to cardiogenic shock. In such cases, the characteristic murmur is less intense, and a thrill may be completely absent. There is a prominent second heart sound, pulmonary hypertension, and possibly tricuspid regurgitation as well.

An atypical presentation has been described with features of VSR emerging as the first manifestation of the disease, after a silent MI [7].

Respiratory Distress
  • On hospital day six, the patient developed acute respiratory distress, a new loud pansystolic murmur, and hemodynamic instability.[ncbi.nlm.nih.gov]
  • Upon admission patient was found in clinical evidence of cardiogenic shock, with developed respiratory distress.[omicsonline.org]
Epigastric Pain
  • CASE PRESENTATION: A 53-year-old Caucasian male presented with epigastric pain for three days and electrocardiographic evidence for an acute inferior wall myocardial infarction.[ncbi.nlm.nih.gov]
Chest Pain
  • Typically VSR may present as worsening of a patient's condition after recent MI, following a short period of clinical stability and usually with complaints of chest pain and dyspnea.[symptoma.com]
  • pain and heaviness.Initial physical examination showed parastemal Ⅲ-Ⅳ systolic murmur.ECG showed a complete right bundle branch conduction blockage.Chest X-ray showed bilateral pulmonary contusion without rib fracture.MB isoenzyme of creatine kinase[cmj.yiigle.com]
  • A 60-years-old male patient, with the history of chronic smoking, presented with progressing chest pain for last 3 days.[ncbi.nlm.nih.gov]
  • Chest pain of recent onset; NICE Clinical Guideline (March 2010, updated Nov 2016) ISBN: 978-1-4731-2182-9. 4. Chan D, Ng LL; Biomarkers in acute myocardial infarction. BMC Med, 2010; 7 (8):34. 5. McCord J.[synapticpg.com]
  • Texto Completo A 69-year-old man was admitted with chest pain lasting for four days. The electrocardiogram showed ST elevation in the inferior leads, with Q waves and inverted T waves.[elsevier.pt]
Heart Disease
  • Provides a clinically based approach to echocardiography, with an in-depth discussion of the main cardiac events seen in practice, including adult congenital heart disease.[books.google.com]
  • Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac[acc.org]
  • Braunwald E, Zipes DP, Libby P (2001) Heart disease: a textbook of cardiovascular medicine 6th edn. WB Saunders Company, Philadelphia Google Scholar 4. Spodick DH (2003) Acute cardiac tamponade.[link.springer.com]

Workup

Medical history and medical imaging are major parts of the diagnostic process. Imaging modalities include:

  • ECG: Which may show signs of myocardial infarction, as well as its location [8].
  • Chest radiograph: Cardiomegaly and features of congestive heart failure may be present, and are easily seen on a plain film.
  • Right heart catheterization: This is a dated method that is no longer commonly used in diagnosis.
  • Doppler echocardiography (DE): DE can also be used as a diagnostic modality [9] [10]. It provides information on the location and extent of rupture, as well as about cardiac function, with a high sensitivity and specificity. The transesophageal method may prove more accurate in severely ill patients.
  • Radionuclide scintigraphy: This test is able to measure the amount of blood shunted through the septal defect, as well as ventricular function.
  • Left ventriculography: This can also be used to diagnose septal rupture.
  • Coronary angiography: This imaging technique is useful in planning a future intervention, particularly revascularization.
Suppression
  • General anesthesia was induced with a combination of fentanyl, ketamine, and propofol, which successfully suppressed fluctuations of hemodynamic variables associated with induction of anesthesia and tracheal intubation.[ncbi.nlm.nih.gov]

Treatment

  • […] and contribute to the treatment of this complex group of patients.[ncbi.nlm.nih.gov]
  • Abstract Although improved treatments for acute myocardial infarction (AMI) have considerably reduced the mortality of AMI in the past two decades, the treatment for ventricular septal rupture (VSR)-a rare but life-threatening mechanical complication[ncbi.nlm.nih.gov]
  • However, when they do occur, they often require urgent invasive treatment.[ncbi.nlm.nih.gov]
  • Since the introduction of reperfusion in the treatment of acute myocardial infarction (AMI), rates of ventricular septal rupture (VSR) and associated mortality have decreased, but it is not known if incidence and mortality have continued to decrease.[ncbi.nlm.nih.gov]
  • It is reasonable to take more active treatments for the patients at high risk to save more lives.[ncbi.nlm.nih.gov]

Prognosis

  • We analyzed the short-term prognosis factors of VSR and established the short-term prognosis index of VSR (SPIV) based on the Logistic regression analysis to stratify patients with VSR.[ncbi.nlm.nih.gov]
  • Although early surgical treatment improves the prognosis of this condition, hospital mortality after emergency surgery ranges from 10% to 60%.[ncbi.nlm.nih.gov]
  • Despite the severity of the setting and the poor prognosis, it was decided to operate.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Despite improvements in medical and interventional techniques the early as well as the long-term prognosis remains poor in this contemporary series.[ncbi.nlm.nih.gov]
  • Abstract Most patients diagnosed with takotsubo cardiomyopathies are expected to almost completely recover, and their prognosis is excellent. However, complications can occur in the acute phase.[ncbi.nlm.nih.gov]

Etiology

  • This paper describes a case with a complex VSR with intramyocardial dissection tract extending throughout the right ventricle and yielding a left to right shunt; where the potential role of ischemia was suspected, but the precise etiology of septal rupture[ncbi.nlm.nih.gov]
  • Intra-aortic balloon pump (IABP) is used in cardiogenic shock of different etiologies.[ncbi.nlm.nih.gov]
  • Cardiogenic Shock Complicating Acute Myocardial Infarction - Etiologies, Management and Outcome: A Report from the SHOCK Trial Registry. J Am Coll Cardiol. 2000;36:1063-70. 6. Birnbaum Y, Fishbein NC, Blanche C, et al.[degruyter.com]
  • Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome: a report from the SHOCK Trial Registry. J Am Coll Cardiol 2000; 36:1063-1070. Lee WY, Cardon L, Slodki SJ.[acc.org]

Epidemiology

  • The epidemiologic design was of an exposed (David infarct exclusion, n 42) versus a nonexposed (Daggett direct closure, n 68) cohort with 3 endpoints: postoperative morbidity, 30-day mortality, and long-term survival.[ncbi.nlm.nih.gov]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
Sex distribution
Age distribution

Pathophysiology

  • However, a growing number of studies consider this anomaly a relevant pathophysiological phenomenon with serious pathological consequences.[ncbi.nlm.nih.gov]
  • This article describes such a transport and reviews the pathophysiology of the process along with treatment options. Copyright 2012 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • Interventricular septal rupture complicating acute myocardial infarction: From pathophysiologic features to the role of invasive and noninvasive diagnostic modalities in current management. Am J Med. 1992;93:683-88.[msjonline.org]
  • Topaz O, Taylor A: Interventricular septal rupture complicating acute myocardial infarction: From pathophysiologic features to the role of invasive and noninvasive diagnostic modalities in current management. Am J Med 1992;93:683–688.[karger.com]

Prevention

  • For the infarct lesion, this approach provides excellent results with sufficient closure of the VSR and prevention of the ventricular remodeling for five years.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Our experience suggests that early V-A ECMO in patients with VSR and refractory CS might prevent irreversible multiorgan failure by improved end-organ perfusion.[ncbi.nlm.nih.gov]
  • In addition, increased stiffness of the patch around the septal defect prevented deformity of the patch and reduced stress on the suture line.[link.springer.com]
  • BACKGROUND: The purpose of this study is to establish a rational surgical design to minimize suture line stress of the patch and thus prevent residual leakage in surgery for post infarction ventricular septal rupture (VSR).[ncbi.nlm.nih.gov]
  • Left ventricular free wall rupture almost always results in hemopericardium (the exception being in the scenario where the patient has had prior open heart surgery and has obliterative fibrous pericardial adhesions; these would prevent egress of blood[en.wikipedia.org]

References

Article

  1. Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation. 2000;101(1):27–32.
  2. Ledakowicz-Polak A, Polak L, Zielińska M. Ventricular septal defect complicating acute myocardial infarction-still an unsolved problem in the invasive treatment era. Cardiovasc Pathol. 2011;20(2):93–98.
  3. Figueras J, Alcalde O, Barrabés JA, et al. Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period. Circulation. 2008;118(25):2783–2789.
  4. Moreyra AE, Huang MS, Wilson AC, Deng Y, Cosgrove NM, Kostis JB. Trends in incidence and mortality rates of ventricular septal rupture during acute myocardial infarction. Am J Cardiol. 2010;106(8):1095-1100.
  5. Lopez-Sendon J, Gurfinkel EP, Lopez de Sa E, et al. Factors related to heart rupture in acute coronary syndromes in the Global Registry of Acute Coronary Events. Eur Heart J. 2010;31(12):1449-1456.
  6. Figueras J, Cortadellas J, Soler-Soler J. Comparison of ventricular septal and left ventricular free wall rupture in acute myocardial infarction. Am J Cardiol 1998;81(4):495-497.
  7. Cox FF, Morshuis WJ, Plokker T, et al. Early mortality after surgical repair of postinfarction ventricular septal rupture: importance of rupture location. Ann Thorac Surg 1996;61(6):1752–1758.
  8. Parry G, Goudevenos J, Adams PC, Reid DS. Septal rupture after myocardial infarction: is very early surgery really worthwhile? Eur Heart J. 1992;13(3):373-382.
  9. Smyllie JH, Sutherland GR, Geuskens R, Dawkins K, Conway N, Roelandt JR. Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction. J Am Coll Cardiol 1990;15(6):1449-1455
  10. Fortin DF, Sheikh KH, Kisslo J. The utility of echocardiography in the diagnostic strategy of postinfarction ventricular septal rupture: a comparison of two-dimensional echocardiography versus Doppler color flow imaging. Am Heart J. 1991;121(1 Pt 1):25-32.

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Last updated: 2018-06-21 20:50