Karina Martinez, n/a: No financial relationships to disclose
Background: Ventricular septal rupture (VSR) is an uncommon mechanical complication of acute myocardial infarction (AMI), occurring in approximately 0.25% of cases. It is associated with refractory cardiogenic shock and high mortality, often necessitating mechanical circulatory support.
Methods: We report a clinical case of a 72-year-old male with cardiovascular risk factors including advanced age, male sex, and smoking. The patient presented to the emergency department 18 hours after the onset of chest discomfort with bradycardia, self-medicating with acetaminophen prior to arrival. Initial 12-lead electrocardiogram demonstrated ST-segment elevation myocardial infarction (STEMI) in the inferior leads with right ventricular involvement. The patient received fibrinolytic therapy with tenecteplase, achieving a door-to-needle time of 20 minutes, but without evidence of successful reperfusion. Following treatment, the patient developed hemodynamic instability requiring high-dose vasopressor and inotropic support, and subsequently underwent invasive mechanical ventilation. New auscultatory findings of a holosystolic murmur with palpable thrill prompted transthoracic echocardiographic assessment, which revealed a ventricular septal rupture with extension of the infarction into the right ventricle.
Outcome: Given refractory cardiogenic shock and progressive hemodynamic decline, mechanical circulatory support with an intra-aortic balloon pump (IABP) was initiated. The patient was admitted to the intensive care unit for aggressive supportive care. Despite maximal therapy, the patient developed multiorgan failure involving renal, hepatic, and hematologic systems, culminating in death 36 hours after admission.
Conclusion: This case underscores the persistently high mortality of ventricular septal rupture despite advances in supportive care. Once cardiogenic shock develops, therapeutic options remain limited. Although multidisciplinary management is essential, definitive surgical repair is often delayed due to myocardial tissue fragility, a strategy frequently unfeasible in severely unstable patients.
