A Fatal Case of Ventricular Septal Rupture Following Inferior ST-Elevation Myocardial Infarction

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/24.00372. Epub January 16, 2025.

A 70-year-old man presented to the emergency department with chest pain for the past 5 days. His cardiovascular history was unremarkable, except for smoking. Upon arrival, the electrocardiogram demonstrated findings consistent with inferior ST-elevation myocardial infarction (STEMI) of late presentation. No cardiac murmurs were detected during clinical examination and auscultation of the lungs revealed no abnormal findings.

The patient was transferred to the coronary care unit and a loading dose of aspirin and ticagrelor was administered. Upon admission, the patient’s arterial blood pressure (BP) was 110/70 mm Hg; he was free of arrhythmic events and reported only minimal symptoms of chest discomfort.

Within 30 minutes, the patient demonstrated rapid deterioration, with a significant drop in arterial BP accompanied by a new onset holosystolic murmur over the precordium, along with a gallop rhythm. Bedside transthoracic echocardiography revealed thickened walls in the left ventricle and an 11-mm-wide ventricular septal rupture with dissection at the junction of the basal inferoseptum and mid-inferoseptum segments (Figure, Videos 1 and 2). Vasopressor support with norepinephrine was initiated. Coronary angiography demonstrated a 100% occlusion at the mid-right coronary artery with the presence of an established thrombus, while there were no critical stenoses in the left coronary system (Video 3). Subsequently, an intra-aortic balloon pump was placed because of severe hemodynamic instability. The patient was transferred to the closest cardiac surgery center for emergency surgical repair of the ventricular septal rupture; however, the patient died a few hours after the surgical procedure.

Since the introduction of primary percutaneous intervention and immediate reperfusion, the incidence of ventricular septal rupture has decreased to less than 1%.¹ However, the mortality rates from this rare mechanical complication remain very high, ranging from 40% to 80% within the first month.² The presence of cardiogenic shock in a patient with myocardial infarction and preserved ejection fraction, combined with the characteristic holosystolic murmur over the precordium, are key indicators for the diagnosis.

Affiliations and Disclosures

Georgios Zormpas, MD¹; Efstratios Karagiannidis, PhD¹; Xanthi Apostolidou, MD¹; Christodoulos E. Papadopoulos, PhD²; George Kassimis, PhD¹; Nikolaos Fragakis, PhD¹; Apostolos Tzikas, PhD^1,3

From the ¹Second Department of Cardiology, Aristotle University of Thessaloniki, Ippokratio General Hospital, Thessaloniki, Greece; ²Third Department of Cardiology, Aristotle University of Thessaloniki, Ippokratio General Hospital, Thessaloniki, Greece; ³Department of Cardiology, European Interbalkan Medical Center, Thessaloniki, Greece.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the interventions described in the manuscript and to the publication of their data.

Address for correspondence: Georgios Zormpas, MD, Second Department of Cardiology, Aristotle University of Thessaloniki, Ippokratio General Hospital Konstantinoupoleos 49 Street, Thessaloniki 54642, Greece. Email: sparky.zorb@gmail.com

References

1.         Cubeddu RJ, Lorusso R, Ronco D, Matteucci M, Axline MS, Moreno PR. Ventricular septal rupture after myocardial infarction: JACC focus seminar 3/5. J Am Coll Cardiol. 2024;83(19):1886-1901. doi:10.1016/j.jacc.2024.01.041

2.         Moreyra AE, Huang MS, Wilson AC, Deng Y, Cosgrove NM, Kostis JB; MIDAS Study Group (MIDAS 13). Trends in incidence and mortality rates of ventricular septal rupture during acute myocardial infarction. Am J Cardiol. 2010;106(8):1095-1100. doi:10.1016/j.amjcard.2010.06.013