Ventricular apical wall rupture and ventricular aneurysm formation concurrent with ventricular septal dissection and rupture due to ST-segment elevation myocardial infarction: a case report.

The most common mechanical complications of acute myocardial infarction include free-wall rupture, ventricular septal rupture (VSR), papillary muscle rupture and pseudoaneurysm. It is rare for a patient to experience more than one mechanical complication simultaneously. Here, we present a case of ST-segment elevation myocardial infarction (STEMI) complicated with three mechanical complications, including ventricular apical wall rupture, ventricular aneurysm formation and ventricular septal dissection (VSD) with VSR. Cardiac auscultation revealed rhythmic S1 and S2 with a grade 3 holosystolic murmur at the left sternal border. Electrocardiogram indicated anterior ventricular STEMI. Serological tests showed a significant elevated troponin I. Bedside echocardiography revealed ventricular apical wall rupture, apical left ventricle aneurysm and VSD with VSR near the apex. This case demonstrates that several rare mechanical complications can occur simultaneously secondary to STEMI and highlights the importance of bedside echocardiography in the early diagnosis of mechanical complications.

Successful repair of recurrent ventricular septal perforation after myocardial infarction using double patch technique via right ventriculotomy: a case report.

BACKGROUND: Post-myocardial infarction (MI) ventricular septal perforation (VSP) is a rare but life-threatening complication. Surgical repair is challenging and carries significant risks, particularly in the context of recurrent VSPs. This case study presents a patient with recurrent VSP after initial surgical repair following myocardial infarction. CASE PRESENTATION: A 65-year-old male were re-administered to our hospital due to recurrent VSP. He was during follow up after undergone emergency VSP closure surgery 2 months earlier, utilizing the bovine double patch technique via left ventriculostomy. The initial VSP was located in the apical part of the interventricular septum, while the recurrent VSP appeared in the upper middle portion of the interventricular septum (Fig. 1). As the previous patch remained intact, the second surgery employed the bovine double patch technique via right ventriculostomy. The patient's condition remained stable without the development of heart failure symptoms. CONCLUSION: Repairing recurrent VSPs remains a challenge, necessitating the mastery of appropriate approaches to achieve optimal outcomes. Further research and guidelines are required to refine management strategies for recurrent VSPs.

Multicentre short- and medium-term report on the device closure of a post-myocardial infarction ventricular septal rupture - In search of risk factors for early mortality.

BACKGROUND: Post-myocardial infarction ventricular septal rupture (VSR) is a rare and severe complication of myocardial infarction. To find early mortality (<30 days) risk factors of device VSR closure and to evaluate its medium-term outcome. METHODS: Multicenter retrospective analysis on all 46 consecutive patients with percutaneous (n = 43) or hybrid (n = 3) VSR closure in 2000-2020 with various nitinol wire mesh occluders. Medical records, hemodynamic data, procedure results, short- and mid-term follow-up were analyzed (4.8 ± 3.7 years, range: 0.1-15, available in 61.7% of patients). Of the patients, 34.8% underwent VSR closure in acute phase (<21 days after VSR occurrence), 17.4% underwent device closure due to significant residual shunt after previous VSR surgery. RESULTS: Success rate was 78.3%. More than moderate residual shunt, major complications, and early surgical reintervention affected 18.9%, 15.2% (including 2 intra-procedural deaths), and 21.7% of patients, respectively. Early mortality was 26.1% (13.9% in successful vs. 70% in unsuccessful closure; p < 0.001). Older age, need for intra-aortic balloon counterpulsation, severe complications, and procedural failure were identified as risk factors for early mortality. Among patients who survived the early period, the 5-year survival rate was 57.1%. NYHA class improved in 88.2% patients at the latest follow-up. CONCLUSIONS: Procedure of VSR device closure demonstrates an acceptable technical success rate; however, the incidence of severe complications and early mortality is notably high. Older patients in poor hemodynamic condition and those with unsuccessful occluder deployment are particularly at a higher risk of a fatal outcome. The prognosis after early survival is promising.

Long-Term Results and Risk Factors of Treatment for Post-Infarction Ventricular Septal Rupture: A Single-Center Experience.

BACKGROUND: Ventricular septal rupture (VSR) following myocardial infarction (MI) is a rare but lethal complication. We analyzed the long-term results and risk factors for survival in the treatment of VSR. METHODS: From January 2012 to December 2021, 115 consecutive patients with post-MI VSR were admitted to our hospital. Depending on different treatment methods patients were divided into following three groups: medical, transcatheter intervention, and surgical repair. During the study, relevant clinical data, operation-related conditions, and follow-up data were analyzed. The Kaplan-Meier method and log-rank test were used to determine the cumulative incidence of mortality. The independent risk factors for patient mortality were evaluated by multivariate logistic regression. RESULTS: The mean follow-up time was 43.4 ± 34.7 months. The overall in-hospital, 30-day, and long-term mortality rates were 24.3%, 38.3%, and 51.3%, respectively. In the medical group, the in-hospital and 30-day mortality rates were 46.7 % (21/45) and 82.2 % (37/45), respectively, with only three patients alive at follow-up. In the transcatheter intervention group, 30-day and long-term mortality rates were 12% and 28%, respectively. In the surgical repair group, 30-day and long-term mortality rates were 8.9% and 22.2%, respectively. Compared with the surgery-group patients, patients with transcatheter intervention had a longer time from VSR to intervention. Logistic regression analysis revealed that age, previous infarction, Killip class, serum creatinine, Troponin T, N-terminal pro-B-type natriuretic peptide, and medical strategy were risk factors for all-cause mortality. CONCLUSIONS: The 30-day and long-term outcomes of patients treated with surgical repair and transcatheter intervention were significantly better than medically treated patients.

A rare case of concurrent left ventricular aneurysm and ventricular septal rupture complicating an inferior myocardial infarction: a case report.

Complications following acute myocardial infarction (MI) such as ventricular septal rupture (VSR) and left ventricular (LV) aneurysm are rare and can be dreadful. Their simultaneous presence in the same patient is extremely rare. We aimed to present a rare case of concomitant association of ventricular aneurysm and VSR complicating an inferior myocardial infarction. We report the unusual case of Mr. A. D, a 63-year-old, active smoker, with a history of diabetes mellitus and hypertension, admitted for the management of inferior MI within 6 days. The MI was complicated by an LV aneurysm in the inferoposterior and the inferoseptal walls associated with a VSR in the inferoseptal wall. The patient had only signs of right heart failure on admission. This observation illustrates on the one hand the rarity of the association of VSR and LV aneurysm after an inferior myocardial infarction, and on the other hand the possibility of founding them at an early stage of MI without any signs of cardiogenic shock.

Percutaneous closure of ventricular septal rupture after myocardial infarction: A retrospective study of 81 cases.

OBJECTIVE: To investigate the efficacy and safety of percutaneous closure of ventricular septal rupture (VSR) after acute myocardial infarction (AMI). METHODS: This retrospective study included 81 patients who underwent transcatheter closure for postinfarction VSR. We analyzed clinical data from hospitalization and the 30-day follow-up, compared clinical data from the survival and death groups, and explored the best closure time and the safety and efficacy of occlusion. The risk factors for death at 30 days were analyzed by logistic regression. RESULTS: C-reactive protein (CRP), white blood cell counts, N-terminal pro brain natriuretic peptide (NT-ProBNP), and aspartate aminotransferase were higher in the death group than in the survival group (p < .01), with a higher rate of application of vasoactive drugs, and a shorter time from AMI to operation (p < .05). At 30 days postocclusion, 19 patients (23.5%) had died. The mortality rate was significantly lower for operation performed 3 weeks after AMI than for operation performed within 3 weeks of AMI (12.5% vs. 48%, p < .001). Devices were successfully implanted in 76 patients, with 16 (21.1%) operation-related complications and 12 (15.8%) valve injuries. Cardiac function improved significantly (p < .001) at discharge (N = 66) and 30 days after procedure (N = 62). Qp/Qs and pulmonary artery systolic pressure decreased significantly, while aortic systolic pressure increased significantly (p < .001). Additionally, EF and LVDd improved (p < .05) after occlusion. Increases in CRP and NT-ProBNP were risk factors for death at 30 days after closure (p < .05). CONCLUSION: Percutaneous VSR closure can be a valuable treatment option for suitable patients with VSR.

Surgical repair of postinfarction ventricular septal rupture: current state of the art.

The incidence of postacute myocardial infarction ventricular septal rupture (post-AMI VSR) has decreased over the past two decades. Nevertheless, individuals who suffer from post-AMI VSR continue to represent a subgroup of patients with high morbidity and mortality. The care for these patients is complex and requires a multidisciplinary approach. However, because of the small number of reports that exist to guide clinical practice, there is a significant variability in care among centers. This review summarizes information on post-AMI VSR diagnosis and outline contemporary best management and practice consideration.

Protocol-based Surgical Intervention to Manage Ventricular Septal Rupture from a Tier Two City.

INTRODUCTION: This study analyzes the outcome of a protocol-based surgical approach for ventricular septal rupture (VSR). The study also clarifies the appropriate time for intervention. METHODS: This is a single-center retrospective analysis of all VSR cases evaluated between February 2006 and March 2020. Cases were managed using the same protocol. Patients were divided into two cohorts - early (those in whom our protocol was instituted within 24 hours of diagnosis) and delayed (intervention between 24 hours and seven days after diagnosis). All-cause mortality was considered as the outcome. RESULTS: The mean age of presentation was 60.1 years, and 75.9% of the patients were men. Cardiogenic shock was the most common mode of presentation. Our analysis validates that once a patient develops VSR, age, sex, comorbidities, left ventricular function, and renal failure at the time of presentation do not have a statistically significant impact on the outcome. The sole factor to have an impact on the outcome was time of intervention. All patients in the delayed cohort expired after surgery, which dragged the overall mortality to 34.5%, whereas 95% of patients in the early cohort are still on follow-up. The mortality in this group was 5% (P≤0.001). CONCLUSION: Early surgical intervention has proven benefits over delayed approach. Surgical intervention in the early part of the disease reduces the risk and thus improves the outcome. The extreme rarity makes VSR an uncommon entity among surgeons. A protocol-based approach makes the team adapt to this unfamiliar situation better.

Clinical characteristics, prognostic factors, and outcomes of ventricular septal rupture in patients with acute myocardial infarction.

Ventricular septal rupture (VSR) is a rare but devastating complication in patients with acute myocardial infarction (AMI). This was a retrospective single-center observational study which aimed to assess the characteristics and outcomes of VSR patients and identify risk factors for in-hospital mortality of VSR patients in the era of percutaneous intervention. Patients with VSR after AMI at the First Affiliated Hospital of Xi'an Jiaotong University from January 2016 to December 2020 were enrolled. Among 5395 consecutive patients with AMI, 42 patients (0.78%) were diagnosed with VSR. Left anterior descending coronary artery was the culprit vessel in most cases (84.4%, 27/32). In the multivariate analysis, female sex (odds ratio (OR): 14.043, 95% confidence interval (CI): 1.396-141.283, p = 0.025) and lower platelet count on admission (OR: 0.979; 95% CI: 0.963-0.995; p = 0.009) were significant risk factors of in-hospital death in VSR patients. In all, 11 patients (26.2%) underwent surgical repair, and the rest were treated medically. The 1-year mortality was lower in the surgical group (36.4%, 4/11) than that in the conservative group (74.2%, 23/31) (p = 0.034). During the follow-up, VSR patients treated surgically tended to have a higher long-term survival rate than those treated medically (log rank χ2 = 5.005, p = 0.025). The prognosis of patients with VSR remained poor in this study. Female sex and lower platelet count were independent risk factors of in-hospital death in VSR patients. The long-term survival rate of patients treated with surgical repair was significantly better than that of patients treated conservatively.

Hyperlactatemia as a Risk Stratification for Postinfarction Ventricular Septal Rupture.

BACKGROUND: Surgical repair for postinfarction ventricular septal rupture (VSR) is a challenging operation, especially in the acute phase with unstable hemodynamics. We retrospectively examined the value of measuring lactate, which can be a quantitative indicator of end-organ ischemia caused by multiple factors including ineffective cardiac output, for risk stratification in patients undergoing surgical repair. METHODS: From April 2008 to December 2018, 33 consecutive patients were admitted to our hospital with a diagnosis of VSR and underwent VSR repair surgery within 24 hours of admission. We categorized patients into 3 groups based on the distribution of preoperative blood lactate level: <5 mmol/L (n = 16), 5 to 10 mmol/L (n = 11), and >10 mmol/L (n = 6). RESULTS: There was no intraoperative death, but the prognosis for patients with lactate >10 mmol/L was extremely poor, with a median postoperative survival time of only 23 days [25th percentile 6, 75th percentile 30]. Five of 6 patients (83%) died within 30 days after surgery. The risk-adjusted hazard ratio (95% confidence interval) for mortality per 1 SD (0.41-unit) increase in log-transformed preoperative lactate level (equivalent to a 4.10-fold increase) was 2.85 (1.57 to 5.19). Patients with lactate 5 to 10 mmol/L had 3.95-fold and those with lactate >10 mmol/L had 6.03-fold higher risk of mortality than those with lactate <5 mmol/L. CONCLUSION: Elevation of preoperative serum lactate is significantly associated with mortality in patients who underwent VSR repair. The findings of this study highlight the value of measuring lactate level for risk stratification.

Optimal surgical timing after post-infarction ventricular septal rupture.

BACKGROUND: Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a dangerous condition. Surgical VSR closure is the definitive therapy, but there is controversy regarding the surgical timing and the bridging therapy between diagnosis and intervention. The objective of this study is to analyze the ideal time of surgical repair and to establish the contribution of mechanical circulatory support (MCS) devices on the prognosis. METHODS: We designed an observational, retrospective, multicenter study, selecting all consecutive patients with post-AMI VSR between January 1, 2008 and December 31, 2018, with non-exclusion criteria. The main objective of this study was to analyze the optimal timing for surgical repair of post-AMI VSR. Secondary endpoints were to determine which factors could influence mortality in the patients of the surgical group. RESULTS: A total of 141 patients were included. We identified lower mortality rates with an odds ratio of 0.3 (0.1-0.9) in patients operated on from day 4 compared with the surgical mortality in the first 24 hours after VSR diagnosis. The use of MCS was more frequent in patients treated with surgery, particularly for intra-aortic balloon pump (IABP; 79.6% vs. 37.8%, p < 0.001), but also for veno-arterial extracorporeal membrane oxygenation (VA-ECMO; 18.2% vs. 6.4%, p = 0.134). Total mortality was 91.5% for conservative management and 52.3% with surgical repair (p < 0.001). CONCLUSIONS: In our study, we observed that the lowest mortality rates in patients with surgical repair of post-AMI VSR were observed in patients operated on from day 4 after diagnosis of VSR, compared to earlier interventions.

Ventricular septal rupture: insights into an old disease.

Ventricular septal rupture (VSR) is a serious complication of ST-elevation myocardial infarction (STEMI) and surgery is the reference treatment. We aimed at describing trends in management and mortality during the last four decades and reporting mortality predictors in these patients. We conducted a single-center retrospective study of patients sustaining a VSR from 1981 to 2020. We screened 274 patients and included 265 for analysis. The number of patients decreased over the years: 80, 88, 56, and 50 in each 10-year time span. In-hospital mortality decreased significantly since 1990 (logrank 0.007). The median age was 72.0 years IQR [66-78] and 188 patients (70.9%) were operated on. IABP was used more routinely (p < 0.0001). In-hospital mortality was assessed at 66.8% (177 patients) and main predictors of death were a time from MI to surgery < 8 days HR 2.7 IC95% [1.9-3.8] p < 0.0001, a Killip class > 2 HR 2.5 IC [1.9-3.4] p < 0.0001 and Euroscore 2 > 20 HR 2.4 IC [1.8-3.2] p < 0.0001. A "time from MI to surgery" of 8 days offers the best ability to discriminate between patients with or without mortality. The ability of "Euroscore 2 and Killip" to detect the patients most likely to wait 8 days for surgery was at 0.81 [0.73-0.89] p < 0.0001. Mortality remains high over the years. Euroscore 2, Killip class, and time from MI to surgery are the main mortality predictors. Patients with a Killip < 3 and a Euroscore < 20 should be monitored at least 8 days since MI before being referred to surgery.

Delayed Presentation of Inferior STEMI Complicated by Ventricular Septal Rupture: An Indirect Consequence of the COVID-19 Pandemic.

The COVID-19 pandemic has adversely impacted healthcare delivery. An indirect consequence of the rational fear of contracting the virus is delayed medical attention for life threatening conditions. We present the case of inferior ST elevation myocardial infarction leading to the rare complication of a ventricular septal rupture reflecting transmural infarction. COVID hesitancy caused a 48-hour delay in seeking medical attention after symptom onset. We also discuss the use of MRI to guide decision for timing of VSD repair in an otherwise asymptomatic patient post-revascularization.

Rotura del septum interventricular post infarto agudo al miocardio: una complicación potencialmente letal Revisión de la literatura a propósito de un caso clínico / Ventricular septal rupture after acute myocardial infarction: a potentially lethal complication Case report and literature review

Rupture of the ventricular septum with the appearance of an interventricular communication is an infrequent and life-threatening mechanical complication after acute myocardial infarction. The advent of coronary reperfusion therapies has reduced the incidence of this complication, but mortality remains high. The clinical presentation varies from mild compromise with exertional dyspnea to severe compromise with cardiogenic shock. In this pathology, early diagnosis is fundamental and surgical repair is the treatment of choice. In this article we report an interesting clinical case about a 77-year-old woman who was belatedly referred to our hospital and diagnosed with postinfarction rupture of the ventricular septum with an unfortunately fatal evolution. Relevance of this case lies in its atypical clinical presentation which led to a delay in diagnosis and a missed opportunity for early reperfusion therapy. An updated literature review about rupture of the ventricular septum complicating acute myocardial infarction was carried out.

Delayed Treatment of Acute Myocardial Infarction With Ventricular Septal Rupture Due to Patient Fear During the COVID-19 Pandemic.

During the coronavirus disease 2019 (COVID-19) pandmic, more patients are presenting with complications late after acute myocardial infarction. We report the case of a 71-year-old man who delayed seeking medical care for 2 weeks, despite progressive shortness of breath, cough, and tactile fever, for fear of contracting COVID-19 in the hospital. Clinical and echocardiographic evaluation revealed a ventricular septal rupture secondary to acute myocardial infarction. The patient underwent urgent cardiac catheterization, followed by successful saphenous vein grafting to the left anterior descending coronary artery and open surgical repair of the ventricular septal rupture with a bovine pericardial patch. This case highlights a potential long-lasting negative effect that the COVID-19 pandemic will have on the care-seeking behavior and health of patients with acute cardiovascular disease.

Use of Levosimendan as bridge therapy to surgical correction of post-infarction ventricular septal defect: a case report.

OBJECTIVE: Ventricular septal defect (VSD) is an uncommon but frequently fatal complication following acute myocardial infarction. In medically treated patients, mortality rates exceed 90%, while the surgical repair is associated with better outcomes, even though optimal surgical timing is still under debate. CASE REPORT: We present the case of a 78-years-old man with no previous remarkable cardiological history admitted to our Emergency Department with the diagnosis of anterior ST-elevation myocardial infarction and significant reduction of left ventricular ejection fraction. The emergency coronary angiography showed sub-occlusion of the left anterior descending coronary artery, treated with stent implantation. The post-procedural echocardiography unveiled the presence of an apical VSD with a large left-to-right shunt, significant right ventricular overload and dysfunction. An intra-aortic balloon pump (IABP) was positioned and, after Heart Team evaluation, a delayed surgical approach was planned. As a bridge to the intervention Levosimendan infusion was administered, on top of IABP support, and a significant improvement in bi-ventricular function and pressure profiles was obtained. Cardiac surgery was successfully performed 9 days after the admission without periprocedural complications. CONCLUSIONS: This unique case supports the use of Levosimendan as a valid pharmacological strategy for perioperative management of VSD.

The Triple-Layer Patch Technique for Postinfarction Ventricular Septal Rupture.

Postinfarction ventricular septal rupture (VSR) represents a well-known mechanical complication of myocardial infarction, determining cardiogenic shock with high mortality rates. Surgical correction requires significant expertise to avoid cardiac rupture, uncontrollable bleeding, residual shunts, heart failure, and death. In the last year, we observed a substantial increase of VSR at our hospital, related to the delayed presentation of people with acute chest pain to the emergency departments during the coronavirus disease 2019 pandemic. We discuss our innovative triple-layer patch technique in a recent consecutive series of 8 patients. This technique proved effective in all patients, with no residual shunt or cardiac rupture.

Ventricular septal rupture and cardiogenic shock complicating STEMI during COVID-19 pandemic: An old foe re-emerges.

The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant.