Ventricular septal defect complicating acute myocardial infarction. Echocardiographic demonstration confirmed by angiocardiograms and surgery

Ventricular septal rupture detected by cross-sectional echocardiography

Cross-sectional echocardiography was used to directly visualize abnormal wall motion and detect the site of ventricular septal rupture in a patient with acute inferior myocardial infarction. The presence of the defect was confirmed by injecting indocyanine green into the left ventricle at the time of cardiac catheterization. Cross-sectional echocardiography provides a rapid, atraumatic means for evaluating patients with complicated acute myocardial infarction.

Echocardiography in acute and remote myocardial infarction

Two dimensional echocardiography is just beginning to be used to characterize cardiac damage in patients with acute myocardial infarction. The two dimensional approach allows for a more comprehensive evaluation of cardiac anatomy and is able to detect with high sensitivity changes in regional wall motion that previously were sometimes missed or only found with difficulty using M mode echocardiography. Two dimensional echocardiography appears to offer a basis for quantifying the extent of myocardial damage in acute myocardial infarction and thus may permit objective assessment of therapeutic modalities and prognosis. In addition, the technique facilitates recognition of specific complications in acute myocardial infarction. In particular, the technique offers te ability to distinguish true from false ventricular aneurysm, postinfarction ventricular septal defect from papillary muscle dysfunction and rupture, and right ventricular infarction from cardiac tamponade.

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.

Perforation of the interventricular septum complicating myocardial infarction

The presentation and management of 21 patients with postinfarction ventricular septal defect (VSD) in whom surgical treatment was considered or performed since 1970 have been analysed and reviewed. An acute group of 11 patients, each of whom developed cardiogenic shock, 9 of whom came to surgery within one week from the onset of their VSD, had a poor outlook, only 27% becoming long-term survivors. Six patients were classified as subacute because their surgery was precipitated by worsening congestive cardiac failure in all, and by pulmonary oedema at the time of surgery in three patients. Four chronic patients were operated upon electively. The results in the subacute and chronic groups were excellent, and all are long-term survivors. Operative closure of the defect is best achieved by the use of a patch. Infarctectomy and aneurysmectomy are necessary in more than half of the cases. Left ventricular assistance by the intra-aortic balloon counterpulsation catheter has been disappointing and did not contribute to long-term survival. The major factor determining survival is the integrity of the closure, and the function of the remaining viable myocardium. Reoperation for reopening of the defect should always be considered.