Grand Rounds - Hammersmith Hospital: Complicated myocardial infarction Ventricular septal rupture is a surgical emergency

Case history

A 64 year old woman was admitted with a three day history of severe retrosternal chest pain followed by progressively worsening dyspnoea at rest. Myocardial infarction was diagnosed, but the delay in admission precluded thrombolysis. Two days later she was transferred to this hospital with breathlessness and oliguria (480 ml over 24 hours) despite having been given intravenous diuretics and low dose dopamine. She had no history of heart disease or hypertension or known coronary risk factors.

On examination she was unwell and mentally obtunded, with cool peripheries and a raised jugular venous pressure. The rhythm was sinus (rate 113 beats/min) and blood pressure 100/65 mm Hg. Her cardiac impulse was laterally displaced, and she had a loud pansystolic murmur, with a palpable thrill, at the lower left sternal border.

Chest radiography showed cardiomegaly, and an electrocardiogram showed evidence of recent extensive anterior myocardial infarction with Q waves in leads V1-6. Her plasma sodium concentration was 123 mmol/l, urea concentration 46.5 mmol/l, and creatinine concentration 209 μmol/l. An echocardiogram showed anteroseptal-apical dyskinesia with infarct expansion, dilated ventricles and impaired biventricular function, and anteroapical septal rupture: colour Doppler ultrasound examination showed shunting and no evidence of mitral regurgitation (fig 1). Swan-Ganz catheterisation showed a pulmonary artery oxygen saturation of 88% and a pressure of 50/23 mm Hg. Ventricular septal rupture with incipient cardiogenic shock was diagnosed, and the circulation was supported with inotropic drugs and intra-aortic balloon counterpulsation pending emergency surgical …