Ventricular Septal Rupture Complicating Silent Myocardial Infarction

A 55-year-old gentleman with no significant past medical history except cigarette smoking presented to the emergency department with shortness of breath for the past 3 days. No associated symptoms of chest pain were reported. Upon arrival, he was normotensive with normal oxygen saturation on room air. An electrocardiogram showed sinus rhythm with inferior Q waves. Blood work showed elevated troponin and brain natriuretic peptide (BNP). A chest X-ray showed pulmonary edema. A transthoracic echocardiogram demonstrated large inferoseptal ventricular septal rupture (VSR) with left-to-right shunt and hyperdynamic left ventricle (Figure 1 A, B; Videos 1, 2). Cardiac magnetic resonance imaging followed to assess intracardiac shunting and a mechanism of VSR, showing significant left-to-right shunting and Qp:Qs of 4:1. There was transmural myocardial infarction (Figure 1 C, D; Video 3) as well as an aneurysm at the diaphragmatic inferior wall of the left ventricle (LV) (Figure 1 E). Subsequent left heart catheterization showed complete occlusion of the right coronary artery and severe stenosis of obtuse marginal 1 (OM1). An intra-aortic balloon pump was inserted in anticipation of surgery. Intraoperatively, there was extensive necrosis of the entire inferior LV wall and inferior septum with a 2.5-cm septal defect near the base of the heart. The patient underwent exclusion patch repair with bovine pericardium of VSR and coronary artery bypass grafting to OM1 with extracorporeal membrane oxygenation support. He underwent cardiac computed tomography, which showed a small residual VSD (Figure 1 F, G; Video 4). He eventually recovered after a long hospital stay and was discharged home.

Figure 1