Inferior infarction complicated by ruptured interventricular septum.


Abstract

A 58 year old male patient with hypertension was admitted at a peripheral hospital after 10 days history of angina, where a diagnosis of inferior STEMI was made. A coronary angiogram showed 3 vessel coronary artery disease with occlusion of the RCA and an 85% stenosis of the LAD. A PCI resulted in successful opening of the RCA and reperfusion of the inferior wall. The next day another PCI to the proximal LAD was successful resulting in revascularisation of the anterior wall. Some hour after the procedure the patient complained of recurrent chest pain and a 12 lead ECG showed clear evidence for a new anterior ST-elevation. A first trans-thoracic echocardiogram (TTE) raised a suspicion of interventricular septal rupture. The patient was therefore transferred in a hemodynamically stable condition to Umea Heart Centre where another TTE was performed during admission which confirmed the provisional diagnosis. The rupture was channel shaped giving a typical left – to –right shunt. The RV was not enlarged, maintaining a satisfactory systolic function. No mitral insufficiency of importance was observed. Considering the overall clinical condition the surgeons decided to postpone the surgical treatment until sufficient repair of the infarcted tissue had occurred. The patient was then discharged with a carefully planned follow-up program.


A 58 year old male patient with hypertension was admitted at a peripheral hospital after 10 days history of angina, where a diagnosis of inferior STEMI was made. A coronary angiogram showed 3 vessel coronary artery disease with occlusion of the RCA and an 85% stenosis of the LAD. A PCI resulted in successful opening of the RCA and reperfusion of the inferior wall. The next day another PCI to the proximal LAD was successful resulting in revascularisation of the anterior wall. Some hour after the procedure the patient complained of recurrent chest pain and a 12 lead ECG showed clear evidence for a new anterior ST-elevation. A first trans-thoracic echocardiogram (TTE) raised a suspicion of interventricular septal rupture. The patient was therefore transferred in a hemodynamically stable condition to Umea Heart Centre where another TTE was performed during admission which confirmed the provisional diagnosis. The rupture was channel-shaped giving a typical left – to –right shunt. The RV was not enlarged, maintaining a satisfactory systolic function. No mitral insufficiency of importance was observed. Considering the overall clinical condition the surgeons decided to postpone the surgical treatment until sufficient repair of the infarcted tissue had occurred. The patient was then discharged with a carefully planned follow-up program.

Figure 1

Apical 4 chamber view with posterior tilting to demonstrate the proximal septal defect and the colour Doppler across it

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Figure 2

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Figure 3

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Figure 4

Respective images showing the intramyocardial tunel like defect on 2 D and colour Doppler

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Several weeks later the patients was re-admitted in a stable hemodynamic condition for elective surgery. A TTE was performed and showed a large VSD with systolic left – right shunt and a right ventricular volume overload. The patient underwent a surgical repair of the defect and was discharged 7 days after surgery.