Acute Dyspnea After Inferior-Wall Myocardial Infarction

J INVASIVE CARDIOL 2021;33(10):E834.

Key words: inferior-wall myocardial infarction, ventricular septal rupture

A 57-year-old female patient presented to the emergency room with acute-onset dyspnea for 2 days. She was thrombolyzed with streptokinase 4 days prior for inferior wall myocardial infarction (MI) in a nearby hospital. Her exam showed elevated jugular venous pressure and systolic murmur in the left lower parasternal region. Electrocardiogram showed Q waves in inferior leads. Echocardiography (Figure 1B; Video 1) showed an akinetic inferior wall. In addition, there was a ventricular septal rupture in the posterobasal interventricular septum, with at least 2 exit points into the right ventricle. The posterobasal appeared to have dissected, leading to communication between the left and right ventricles. Coronary angiography showed a normal left coronary artery and complete occlusion of the right coronary artery (RCA). There were no collaterals from the left system to the RCA. Left ventricular angiogram (Figure 1A; Video 1) was done with a pigtail catheter, which showed ventricular septal defect with diffuse contrast filling of the right ventricle. This was suggestive of multiple entry points into the right ventricle. Since there were multiple exit points, device closure could not be contemplated. The patient was stabilized with optimal medical therapy and planned for ventricular septal repair after 28 days, as in the immediate aftermath of ST-segment elevation MI, the septum will be friable and increase the difficulty of suture application. The patient underwent patch repair elsewhere and is currently doing well.

Ventricular septal rupture has a bimodal presentation. Presentation in 24 hours is usually due to septal dissection and those presenting in 3-5 days are due to coagulative necrosis. Ventricular septal rupture in inferior-wall MI is commonly due to dissection, mainly due to hypercontractile left anterior descending artery territory. Timely identification of ventricular septal rupture before percutaneous coronary intervention is of paramount importance, as it has major implications for the management of the patient.