Multimodality cardiac imaging of a ventricular septal rupture post myocardial infarction: a case report

Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.

Cardiac MRI-guided interventional occlusion of ventricular septal rupture in a patient with cobalt alloy stent

The case of a 68-year-old man with chest pain for 3 days is presented. Coronary angiography demonstrated subtotal occlusion of the mid-left anterior descending artery. A drug-eluting cobalt alloy stent was implanted after balloon dilation. On the 3^rd postoperative day, echocardiography showed a ventricular septal rupture (VSR) (7 mm diameter) near the cardiac apex and ventricular aneurysm. On cardiac magnetic resonance imaging (MRI), the VSR was shown to be 11 mm in diameter. The membranous septum was 32 and 27.8 mm along the anteroposterior and superoinferior axes, respectively. The left-to-right shunt was apparent. Four weeks later, interventional therapy was performed to occlude the VSR according to the result of the MRI. The symptoms improved rapidly, and the patient was discharged. At the 4-month follow up visit, cardiac MRI revealed no shunt at the occlusion site, and the edge of the occluder was secured in the adjacent normal cardiac tissues. In conclusion, cardiac MRI could be considered for patients with a newly implanted cobalt alloy stent to provide an accurate assessment of VSR.

Utility of cardiac MRI in determining percutaneous versus surgical post-infarction ventricular septal defect repair

AIM

Postmyocardial infarction ventricular septal defect (VSD) is a rare complication that can lead to rapid hemodynamic patient decompensation. The type of VSD repair relies on several factors including: size, location, timing and surgical expertise.

CASE

A 63-year-old man with a ST-elevation myocardial infarction underwent percutaneous coronary intervention of the right coronary artery. A holosystolic murmur was notable postcatheterization, and transthoracic echocardiogram confirmed a VSD. To characterize the VSD, a cardiac MRI demonstrated a large, serpiginous VSD and longitudinal septal tear. Given the anatomic complexity and stable hemodynamics, a surgical trans-left ventricular patch repair was performed.

CONCLUSION

We emphasize the importance of cardiac magnetic resonance as a decision-making tool, utilizing imaging to ascertain the anatomy combined with hemodynamics to determine optimal individualized therapy.

Cardiac MRI of acute coronary syndrome

Acute coronary syndrome (ACS) is a major cause of morbidity and mortality worldwide. New serological biomarkers, such as troponins, have improved the diagnosis of ACS; however, the diagnosis of ACS can still be difficult as there is marked heterogeneity in its presentation and significant overlap with other disorders presenting with chest pain. Evidence is accumulating that cardiac MRI provides information that can aid the detection and differential diagnosis of ACS, guide clinical decision-making and improve risk-stratification after an event. In this review, we present the relevant cardiac MRI techniques that can be used to detect ACS accurately, provide differential diagnosis, identify the sequelae of ACS, and determine prognostication after ACS.