Cardiology Fellow Cardiovascular Institute, Northwell Health Manhasset, New York, United States
Disclosure(s):
Kirpal S. Kochar, MD: No financial relationships to disclose
Background: Ventricular septal rupture (VSR) is an uncommon yet serious complication following a myocardial infarction (MI) that presents a series of challenges in immediate management. Recent studies have demonstrated the benefits of temporary microaxial mechanical support in the optimization of hemodynamics prior to delayed, non-emergent surgical repair of a post-MI VSR.
Methods: A 61 year old female presented with 3 days of shortness of breath and chest pain. A 12-lead EKG demonstrated sinus tachycardia with inferior ST elevations, while vitals were notable for normal blood pressure but profound hypoxia. The patient’s course in the ED was complicated by altered mental status and unstable ventricular tachycardia (VT) requiring intubation and cardioversion. The patient was transferred to a tertiary care center for further care, where there was a rapid increase in pressor and inotrope requirement. Initial hemodynamics from a Swan-Ganz catheter were notable for a CVP of 12 mmHg, PA 40/23 mmHg, Fick cardiac output (CO)/cardiac index (CI) 13.4/8.3, and thermal dilution CO/CI 3.8/2.4. Simultaneous RA and PA O2 saturations were 59.6% and 87.7% respectively. Transthoracic echocardiogram (TTE) revealed a left ventricular ejection fraction (LVEF) of 35% as well as a VSR of the basal inferoseptum with left to right shunting. The patient’s ICU course was complicated by worsening end organ perfusion and hemodynamics which prompted a multidisciplinary discussion and insertion of an axillary Impella 5.5 device.
Outcome: Initial post-Impella hemodynamics were notable for a CVP of 12 mmHg, PA 29/11 mmHg, CI 3.08, and Qp/Qs 3 on P8 support with 4.4 LPM of flow. On hospital day 4, the patient’s hemodynamics improved with a CVP of 6 mmHg, PA 30/4 mmHg, CI 3.6, and Qp/Qs of 1.5 on P8 support with 4.3 LPM of flow. A left heart catheterization demonstrated an occluded mid-RCA but patent LAD and Left Circumflex vessels. On hospital day 10, the patient underwent a successful surgical VSR and tricuspid valve repair with delayed sternal closure due to severe coagulopathy. Following surgical repair of the VSR, the patient’s LVEF improved to 55% on post-operative day 22. The patient was discharged to rehab on post-operative day 33, and then to home on post-operative day 42.
Conclusion: Post-MI VSR poses a challenging scenario that requires a multidisciplinary approach to effectively identify and treat patients who are candidates for surgical repair. Although guidelines recommend urgent surgical intervention, utilization of temporary microaxial mechanical support can be an effective strategy in the optimization of hemodynamics and improvement of surgical outcomes.
