Case report Surgical treatment of interventricular septum rupture in an 87-year-old female with acute antero-lateral myocardial infarction and 97% risk according to the Euroscore scale
Zbigniew JuraszyńskiJoanna KotlarskaWojciech DrewniakKrzysztof KotlińskiIwona HuńkaMarcin BorysMarek Dąbrowski
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Abstract:
Rupture of the interventricular septum is a serious complication of myocardial infraction (MI). It occurs in 1-3% of all MI cases, usually within 2 weeks after infraction. In 60% of the cases post-MI ventricular septal defects (VSD) are the result of completely occluded coronary artery supplying anterior wall of left ventricle and subsequent transmural MI. 50% of patients die within the first week after the rupture unless they are surgically treated. In this case report we describe an 87-year-old woman with post-MI VSD who was successfully operated (endocardial patch exclusion technique, proposed by David). In spite of a very high predicted risk (97% by Euroscore), calculated high risk should not be considered as the contraindication for life-saving operation.Keywords:
Interventricular septum
Contraindication
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An 85-year-old man was hospitalized with infero-lateral myocardial infarction (MI). The time interval from onset to reperfusion was 8 h. During angiography, the patient suddenly developed cardiogenic shock. Moderate size pericardial effusion and oozing through a posterior wall rupture of left ventricle (LV) were detected on echocardiography ( Panel A , arrow). Since the risk of surgery was extremely high, a surgical treatment was not undertaken in agreement with the surgical team. After …
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Ventricular septal defect (VSD) is a severe complication of acute myocardial infarction and has a high mortality rate. This complication appears to have declined in the reperfusion era. It has mostly been reported in elderly or female patients who suffer from anterior wall infarction, patients with multivessel coronary artery disease (CAD) or occluded infarct‐related artery (IRA) without collateral circulation, or patients who have had delayed reperfusion therapy. Here, we report the case of a 60‐year‐old male patient who presented with persistent chest pain and Killip I ST‐segment‐elevation myocardial infarction. Thrombolytic therapy was started 3 hours after the onset of chest pain. Based on the subsidence of chest pain, resolution of the elevated ST segment, and early peak of cardiac enzymes, reperfusion was thought to be successful. However, on the third day of admission, the patient complained of dyspnea after defecation and was found to have new‐onset grade 3 pansystolic murmur over the left sternal border. Cardiac echography showed an apical VSD. A Swan‐Ganz catheter was inserted into the right side of the heart; analysis of blood oxygen saturation revealed a 6% step‐up of oxygen in the right ventricle. Coronary angiography showed only one‐vessel CAD and TIMI 3 flow in the IRA. The patient received intensive medical management and underwent VSD repair and internal mammary artery bypass grafting to the left anterior descending artery. His recovery was uneventful. This case illustrates that VSD can be found in patients receiving early successful reperfusion therapy, with one‐vessel CAD, and TIMI 3 flow in the IRA.
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We reviewed 16 patients with ventricular septal rupture complicating myocardial infarction who underwent surgical repair between January 1984 and August 1987. Nine of them had anterior acute myocardial infarction (56%) and 7 inferior acute myocardial infarction (44%). The overall surgical mortality was 43.8%; in the group of patients with early treatment (less than 15 days after acute myocardial infarction) the mortality was 55%, while in the group with later treatment (16-30 days) the mortality was 28% (p-NS). Survival was unrelated to preoperative evidence of shock, magnitude of the shunt or the extent of coronary artery disease. We found a better in-hospital survival in the group of patients with ventricular septal rupture complicating anterior acute myocardial infarction (77%) vs inferior acute myocardial infarction (28%) with statistical significance (p less than 0.05). After a follow-up ranging from 1 to 40 months (mean: 17 months), 78% of the in-hospital survivors were alive and they were all in NYHA class II-III. We conclude that the major determinant of in-hospital survival in our patients was the anatomical site of acute myocardial infarction. Furthermore, we believe that the surgical repair of the ventricular septal defect is helpful in modifying the negative outcome of such an acute myocardial infarction complication.
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Interventricular septum
Heart Rupture
Ventricular aneurysm
Left Ventricular Aneurysm
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To assess the diagnostic and treatment methods of ventricular septal rupture following myocardial infarction in a small patient population.Retrospective medical record review.Four Honolulu area teaching hospitals.Eighteen patients with ventricular septal rupture (VSR) following myocardial infarction (MI) between 1979 and 1993.Ventricular septal rupture occurred more frequently in the elderly, in females and in those presenting for the first time with an MI. Thirteen patients (72%) underwent surgical repair including the two survivors. Three patients (17%) also underwent coronary artery bypass grafting, one of who survived. Very few of the patients had a history of stable angina pectoris before MI. Sudden deterioration in the patient's condition as manifested by tachycardia, hypotension and signs of right heart failure in those with an acute MI, especially if accompanied by a systolic murmur should encourage a search for a mechanical cause, especially a VSR.Two dimensional echocardiography or Swan-Ganz catheterization is 100% diagnostic and can be rapidly done at the bed side. Early surgical repair is important to the overall prognosis.
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The authors report their experience with combined investigation and surgical treatment of patients with threatened myocardial infarction and those with postinfarction rupture of the interventricular septum. Direct reconstruction of coronary arteries was performed in 12 of 17 patients with threatened myocardial infarction (three patients died, two of cardiac complications). In the survivors, anginal signs either disappeared or became less pronounced. The correction of interventricular septum rupture was performed in 8 patients, three of whom died. The remaining five patients showed obvious improvement.
Interventricular septum
Coronary arteries
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In the era before reperfusion therapy, ventricular septal rupture complicated 1approximate3% of acute myocardial infarctions (AMI) usually 3-5 days after onset. Studies have reported a positive correlation between the incidence of septal perforation and total occlusion of the coronary arteries. A 70-year old female patient was referred to the emergency room with the diagnosis of acute anterior myocardial infarction (MI) and recent cerebral infarction. The coronary angiogram showed a 90% stenosis at the mid-portion of the left anterior descending artery (LAD), and the lesion was successfully treated by percutaneous coronary intervention (PCI) with stent implantation. After PCI, the anterior wall motion improved on the follow-up echocardiogram. However, on the 20th hospital day, the patient condition deteriorated suddenly with pulmonary congestion. The echocardiography revealed a 1.3 cm ventricular septal defect at the apical septum with a left-to-right shunt. We report this rare case of delayed septal rupture in a patient with patent LAD after PCI and recovery of wall motion.
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Objectives To summary the efficacy of surgical treatment in patients with ventricular septal rupture after acute myocardial infarction.Methods From January 2006 to December 2009,clinical data of 10 patients with ventricular septal rupture after acute myocardial infarction were retrospectively analized and the efficacy of surgical treatment were focued on.Among them,5 cases performed ventricular aneurysm resection and 1 patient underwent coronary artery bypass grafting at the same period.Results There were 2 perioperative deaths because of severe low cardiac output syndrome.No residual shunt ventricular septal were found in all patients and mild mitral egurgitation were found in 7 cases.Echocardiography showed that postoperative left ventricular end diastolic diameter(LVEDD) reduced compared with that before operation and the difference was not significent[(54.0±8.2) mm vs.(48.0±8.3)mm,t=1.6262,P=0.1213 ];left ventricular ejection fraction(LVEF) increased,but the difference had no significance(48%±12% vs.50%±6.2%,t=0.4682,P=0.6452).Conclusions Surgical treatment is a effective treatment for ventricular septal perforation after acute myocardial infarction.To choose reasonable timing of surgery and make aggressive treatment of perioperative can significantly improve survival rates.
Ventricular aneurysm
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Objective:To investigate the clinical features,performance of coronary angiography,treatment strategies and prognosis in patients with ventricular septal rupture after acute myocardial infarction(AMI). Method:From January 2003 to October 2011,8 patients were diagnosed acute ST-segment elevation myocardial infarction. Result:Four patients(50.0%) had hypertension,3(37.5%) had diabetes history and 1(12.5%) had smoking history;7(87.5%) had anterior myocardial infarction,1(12.5%) had inferior wall myocardial infarction.Cardiac function(Killip) of 5(62.5%) patients were Ⅳ grade,3(37.5%) were Ⅲ grade.Persistent chest pain for 14-336 hours.Ehocardiography prompted ventricular septal defection with 6-22 mm diameter,were located in interventricular septum near the apex.Five cases were implanted intra-aortic balloon pump(IABP) to support cycle function.Only 5 patients were underwent PCI.Seven patients died,total mortality was 87.5%,7 patients with medical treatment were died,the mortality rate of was up to 100%. Conclusion:AMI complicated by ventricular septal rupture is rare,mostly in patients with extensive anterior myocardial infarction.The medical treatment mortality is high.If we opened culprit vessel as early as possible and supported with vasoactive drug therapy or IABP treatment,then maintained hemodynamic stability for 4~8 weeks until undergo ventricular septal perforation repair,the survival rate can be improved.
Interventricular septum
Perforation
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