Heart Science Journal 2025.
: 105-109
Contents list available at w.
Case Report Unveiling strategies in acute cardiac care for ventricular septal rupture following acute myocardial infarction: Lessons from cases Akhmad Isna Nurudinulloh1,3*.
Setyasih Anjarwani2,3.
Indra Prasetya2,3.
Valerinna Yogibuana2,3.
Anna Fuji Rahimah2,3.
Wella Karolina2,3 1Brawijaya Cardiovascular Research Center.
Department of Cardiology and Vascular Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia.
2Department of Cardiology and Vascular Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia.
3 Dr.
Saiful Anwar General Hospital.
Malang.
East Java.
Indonesia
ARTICLE INFO
ABSTRACT
Keyword :
Acute Cardiac Care IABP.
Percutaneous VSR Closure.
Ventricular Septal Rupture.
Background: Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is drastically decreasing in the reperfusion era but mortality remains high.
VSR correction is the definitive treatment and using mechanical support to delay closure is an attractive option despite data on success being limited.
Case Illustration: A 60-year-old man presented with late presentation of anterior STEMI complicating hemodynamic Echocardiography showed apical VSR 11-14 mm L-R shunt.
Patient was given adequate fluids, multiple inotropic agents, and IABP insertion, then a successful PPCI procedure was performed immediately.
IABP was maintained for hemodynamic stabilization and patient was scheduled for interventional closure.
Unfortunately, the patient worsened due to cardiogenic shock and passed away on the 5th day of admission.
In another case, a 61-year-old man came to our hospital also with a late presentation of anterior STEMI but stable in Echocardiography showed apical VSR 9-11 mm L-R shunt.
Coronary angiography showed CAD three vessel disease with critical stenosis at LAD.
In hospitalAos heart team discussion, patient was planned to be performed VSR closure percutaneously and continue with PCI procedure.
Both procedures were performed successfully.
Patient was improved and discharged on 20th day of admission.
Conclusion: Rapid diagnosis and prompt treatment are the keys to optimal management of VSR complicating late presentation STEMI.
Mechanical circulatory support and correction of VSR are required to optimize patient outcomes despite VSR is still a challenging case.
Introduction Ventricular septal rupture (VSR) is a rare but potentially lethal mechanical complication that can occur after acute myocardial infarction (AMI).
In the absence of reperfusion therapy, around 1-3% of patients with AMI will develop VSR.
With the reperfusion treatment era, the occurrence of post-MI VSR has decreased to a range of 0.
2Ae 1,2 Usually.
VSR becomes apparent within three to five days following myocardial infarction.
Non-HLA gene polymorphisms have been shown to influence the immune response in viral infections such as dengue, and similarly, these polymorphisms may also impact the bodyAos response to post-myocardial infarction complications like VSR.
3 Even with optimal medical treatment, the mortality rate for this mechanical complication still stands at approximately 40%.
4 Studies have shown that early intervention in managing severe conditions, such as cirrhosis or rheumatoid arthritis, significantly impacts mortality rates, a concept that is similarly applicable in the management of VSR.
For example, research highlights the importance of timely prognostic interventions in patients with cirrhosis, which can help reduce mortality, a principle that aligns with the urgent management required for VSR.
Additionally, early cardiovascular interventions have been shown to improve outcomes in patients with rheumatoid arthritis, emphasizing the need for rapid intervention in cases of VSR.
The article presents two case studies of VSR, one with an unstable patient who required multiple inotropic drugs and intraaortic balloon pump (IABP), and another with a stable patient who underwent successful VSR closure through a transcutaneous procedure.
This report provides valuable information regarding the timing of occurrence, potential risks, clinical features, outcomes of VSR that complicated AMI, and acute cardiac care strategies.
Case Presentation Case 1 A 60-year-old man who came to the emergency room (ER) Saiful Anwar Hospital Malang was referred from another hospital complaining of crescendo angina that began 4 days prior to admission, as well as shortness of breath and cold sweats.
The risk factors are hypertension, diabetes mellitus type II, and active smoking.
Physical examination showed shock condition with blood pressure 105/55 mmHg on inotropic drugs norepinephrine 0.
5 mcg/kgbw/min and dobutamine 10 mcg/kgbw/min.
A pansystolic murmurs were heard around the lower left sternal border (LLSB) without CarvalloAos sign.
The auscultation also heard bilateral rales indicating congestive sign.
The ECG showed deep pathological Q wave with ST-elevation at segments V1-V4.
The chest x-ray showed cardiomegaly with left ventricular hypertrophy (LVH) configuration with congestive pulmonum.
The patient was diagnosed with late-onset ST-elevation myocardial infarction (STEMI) Killip IV.
The patient was then performed endotracheal intubation for airway and breathing support and then transported to the catheterization lab for primary percutaneous coronary intervention (PCI) with the support of multiple inotropic drugs.
* Corresponding author at: Brawijaya Cardiovascular Research Center.
Department of Cardiology and Vascular Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia.
-Dr.
Saiful Anwar General Hospital.
Malang.
East Java.
Indonesia E-mail address: akhmadisna@gmail.
com (A.
Nurudinullo.
https://doi.
org/10.
21776/ub.
Received 2 October 2024.
Received in revised form 3 January 2025.
Accepted 3 January 2025.
Available online 30 April 2025 A.
Nurudinulloh, et al.
Heart Science Journal 2025.
: 105-109
Because hemodynamics was deteriorating, intra-aortic balloon pump (IABP) implantation was performed first.
Primary PCI was performed via femoral access.
Angiography showed two-vessel disease with total occlusion in the proximal left anterior descending (LAD) with no collateral vessels found.
No complications were found when wiring and ballooning were carried out.
A drug-eluting stent 3.
0 mm x 25 mm was implanted in the proximal-mid LAD but only obtained a TIMI flow The patient was transferred to the cardiovascular care unit (CVCU) for further management.
The heparinization was continued for at least 5 Trans-thoracal Echocardiography (TTE) examination showed an ejection fraction (EF) of 29%, normal heart dimensions with LVH concentric, and an 11-14 mm VSR in the apical segment with a left-toright shunt.
Diagnostic coronary angiography showed critical stenosis at proximal LAD with TIMI Flow 3.
The patient's condition worsened further during postprimary PCI treatment in the CVCU.
Cardiogenic shock and acute pulmonary edema occurred, necessitating the use of multiple inotropic medications with norepinephrine, dobutamine, and epinephrine support up to maximal doses.
Patient was still with ventilator support and IABP support.
The patient finally passed away on the fifth day of admission due to cardiogenic shock.
Discussion Case 2 A 61-year-old man who came to ER Saiful Anwar Hospital Malang also was referred from another hospital complaining of crescendo angina that began 2 weeks prior to admission.
The risk factors are hypertension and active smoking.
Patient had stable hemodynamics with BP 107/70 mmHg without support.
A pansystolic murmurs were heard around the LLSB without carvalloAos sign.
Auscultation of pulmonary examination was within normal limits.
The ECG showed deep pathological Q wave with ST-elevation at segments V1-V4 back to the baseline.
The chest x-ray showed cardiomegaly with LVH The patient was diagnosed with late-onset STEMI Killip 1.
TTE examination showed EF of 45%, normal heart dimensions with LVH eccentric, and a 13-18 mm VSR in the apical segment with a left-to-right Echocardiography showed sufficient rim to deploy a device Heart team discussion with a multidisciplinary approach involved cardiologists, thoracic surgeons, and anesthesiologists.
The discussion concluded that VSR closure will perform percutaneously and continue with PCI procedure with a backup from the thoracic surgical VSD occluder then was implanted well to VSR area.
After that, the PCI procedure was performed.
A drug-eluting stent 3.
0 mm x 28 mm was implanted in the proximal-mid LAD with TIMI flow 3 results and no residual stenosis.
Patient then followed up until 20 days of care.
The patient was improved and discharged on 20th day of admission.
VSR is a rare and severe complication of late-onset STEMI associated with high mortality rates.
The incidence of VSR was 1Ae2% in the pre-thrombolysis era, with a subsequent decline following the introduction of thrombolytic therapy.
7,8 Anterior infarctions are more likely to cause apical defects, while inferior or lateral infarctions typically result in defects at the septal and posterior wall boundaries.
This leads to the formation of a left-to-right shunt.
The clinical presentation of this mechanism varies, including hemodynamic instability, infarction, ischemia, and right ventricular volume overload.
Hemodynamic instability occurs in the majority of patients within a few days to weeks.
Additionally, genetic factors, such as non-HLA gene polymorphisms, have been shown to influence the immune response in various medical conditions, including post-myocardial infarction complications like VSR.
9 The willingness to pay for medical interventions, including those for VSR, can be influenced by socioeconomic factors, as similarly observed in the acceptance of dengue vaccines.
10 This highlights the importance of considering socioeconomic determinants in designing effective healthcare 11 Furthermore, polymorphisms in ACE and bradykinin B2 receptor genes can affect how patients respond to ACE inhibitors, which are commonly prescribed for managing complications like VSR postAMI.
Table 1.
Summary of Cases Characteristics Age .
Sex (M/F) Risk Factors Hypertension Diabetes - Current Smoking - History of CVA Onset Physical Examination BP/HR .
mHg/bp.
Cardiogenic shock
Congestive Condition ECG
Infarct Location Hs Troponin
Echocardiography - EF (%) - VSR finding Inotropic drugs IABP Insertion
DCA
Culprit lesion
Reperfusion therapy VSR Closure Concomitant disease In-Hospital Mortality Case 1
Case 2
4 days 14 days 80/60, 120
ST elevation V1-V5
Deep Q wave V1-V5
Anterior
107/70, 65
ST elevation V1-V4 Deep Q wave V1-V4 Anteroseptal Apicoseptal 11-14 mm Multiple CAD 3VD LM Disease Acute total occlusion proximal LAD Primary PCI Pneumonia.
Septic
Passed away at day 5
Apicoseptal 13-18
CAD 3VD
Critical stenosis proximal LAD
PCI
Transcutaneous Closure Pneumonia A.
Nurudinulloh, et al.
Heart Science Journal 2025.
: 105-109
Figure 1.
(A) ECG showed deep pathological Q wave with ST elevation at anteroseptal leads.
(B) TTE showed apical VSR with a left-to-right shunt.
(C)
Angiography showed total occlusion at LAD.
(D) Post-PCI angiography showed LAD flow improved.
ECG: electrocardiography.
TTE: trans-thoracal VSR: ventricular septal rupture.
LAD: left anterior descending.
PCI: percutaneous coronary intervention.
Figure 2.
(A) TTE showed apical VSR with a left-to-right shunt.
(B) Post-transcatheter VSR closure showed occluder in situ.
(C) Fluoroscopy during transcatheter VSR closure.
(D) PCI procedure on critical stenosis at LAD.
(E) Post PCI showed stenotic lesions improved.
TTE: trans-thoracal VSR: ventricular septal rupture.
LAD: left anterior descending.
PCI: percutaneous coronary intervention.
Nurudinulloh, et al.
Heart Science Journal 2025.
: 105-109
To enhance patient outcomes, it is essential to promptly diagnose and intervene surgically in cases of rapid deterioration during the acute phase of a VSR following a myocardial infarction.
Echocardiography, a portable imaging technology, is highly sensitive and specific.
It is effective for assessing the risk of VSR and determining the need for surgical or percutaneous correction of the septal rupture.
IABP can enhance coronary blood flow while simultaneously lowering ventricular wall stress and myocardial oxygen demand.
Additional mechanical support options, such as extracorporeal membrane oxygenation (ECMO) and percutaneous left ventricular assist devices (LVAD) like Impella, are also utilized, although empirical data on their efficacy remains limited.
These mechanical support systems are anticipated to help maintain hemodynamic stability when the timing of surgical correction is strategically delayed.
Although surgical repair is the definitive treatment for VSR, delaying closure with full mechanical support remains an attractive option despite limited data on its success.
Percutaneous closure of the defect may also be a valuable therapeutic alternative.
In the first case.
VSR was suspected upon the patient's arrival at the emergency department, though it was only confirmed during treatment in the CVCU after primary PCI.
The diagnosis of VSR was often established after primary PCI in patients with late-onset STEMI and cardiogenic shock (Killip IV), considering the necessity to achieve doorto-wire crossing time in this condition.
Echocardiography evaluation showed a VSR with an 11-14 mm shunt from left to right and a reduction in the left ventricular ejection fraction to 29%, necessitating continuous hemodynamic monitoring and therapeutic adjustment.
Optimal shock management is a priority following primary PCI, including the use of IABP and inotropic agents, alongside standard dual antiplatelet therapy and high-intensity statins for STEMI.
13,16 Anticoagulation therapy was also continued post-primary PCI due to low flow in the LAD coronary artery after stenting.
The optimal management of VSR in STEMI was planned with a heart team discussion, considering surgical VSR closure as the primary option.
Declaration 1 Ethics Approval and Consent to participate Patient has provided written informed consent prior to involvement in the study.
Consent for publication Not applicable.
3 Availibility of data and materials Data used in our study were presented in the main text.
4 Competing interests Not applicable.
5 Funding Source Not applicable.
6 Authors contributions Idea/concept: INA.
Design: INA.
Control/supervision: SA.
IP.
VY.
AF.
WK.
Data collection/processing: INA.
Analysis/interpretation: INA.
SA.
IP.
VY.
AF.
WK.
Literature review: INA.
SA.
IP.
VY.
AF.
WK.
Writing the article: INA.
Critical review: SA.
IP.
VY.
AF.
WK.
All authors have critically reviewed and approved the final draft and are possible for the content and similarity index of the manuscript.
7 Acknowledgements We thank to Brawijaya Cardiovascular Research Center
References