Diagnosis of ventricular septal defect in acute myocardial infarction without cardiac catheterization

Successful management of mechanical complications following acute myocardial infarction--a case report

Rupture of the heart as a complication of myocardial infarction is one of the most common causes of in-hospital mortality. Rupture of the free wall of the ventricle or interventricular septum has a poor prognosis when treated conservatively. So, rupture of the heart after infarction requires prompt diagnosis and early surgical repair despite the high overall incidence of early operative mortality before hemodynamic deterioration and multiorgan failures develop. Rupture of the left ventricle results in pseudoaneurysm if the overlying pericardium adhers to the surface of the heart. Pseudoaneurysms which rarely develop after infarction, tend to rupture. Their presence alone is an indicator for operation because of the very poor prognosis following rupture. We experienced successful management of 2 rare complications after acute myocardial infarction: ventricular septal defect and pseudoaneurysm. The first patient was a 49-year-old man who had an apical septal defect. His electrocardiogram showed Q wave in leads V2-V6, II, III, and aVF but a coronary angiogram showed normal findings. He was successfully treated by patch closure of the septal defect. The second patient was a 65-year-old female who had false aneurysm of the left ventricle. She had neither chest pain nor abnormality on the electrocardiogram. A coronary angiogram showed complete occlusion of the distal circumflex artery. Under cardiopulmonary bypass, the neck of the aneurysmal sac was successfully closed with a prolene suture.

Ventricular septal rupture: a review of clinical and physiologic features and an analysis of survival

Forty-one patients with postinfarction ventricular septal rupture were cared for in our hospital during 1971-1975. Cardiogenic shock developed after septal rupture in 55% of these patients. Shock was unrelated to site of infarction, extent of coronary artery disease, left ventricular ejection fraction, or pulmonary-to-systemic flow ratio, but mean pulmonary artery pressure was lower in shock than in nonshock patients. These observations suggest that shock was produced mainly by right ventricular impairment. Perioperative survival was much higher in patients who did not have shock preoperatively (14 of 17 [82+]) than in those who did (three of 11 [27%]). Magnitude of shunt, left ventricular ejection fraction, extent of coronary artery disease, and performance of aortocoronary bypass grafting were not distinctly correlated with perioperative survival. After a minimum 4-year follow-up, 76% of the perioperative survivors are alive, and none suffer more than New York Heart Association functional class II disability. All 13 unoperated patients (11 in shock) died within 3 months.

Ventricular septal defect following myocardial infarction

Review of the literature since 1970 revealed more than 200 patients who had a ventricular septal defect following myocardial infarction and underwnet operation. Pathogenesis and diagnosis are discussed. The primary therapy is operative repair, which is considered from the standpoint of approach, timing, technique, concomitant coronary artery bypass, mortality, and long-term survival. Operative mortality in those patients operated on less than 3 weeks following perforation remains high (40%) but when it is possible to wait 3 weeks, there is a marked decrease in mortality (6%). Several general principles have evolved for the care of these patients. (1) Operation should be deferred until 3 weeks after infarction if possible. (2) The intraaortic balloon allows preoperative evaluation of the patient with clinical hemodynamic deterioration in the early postinfarction period. (3) The incision should be placed through the infarct. (4) Associated coronary artery or mitral valve disease should be repaired as well.