Ventricular septal rupture
Ventricular septal rupture is a mechanical complication of myocardial infarction in which necrosis creates a septal defect and an acute left-to-right shunt, causing biventricular failure and cardiogenic shock days after an infarct, with a new harsh holosystolic murmur and thrill. Diagnosis is by echocardiography with a right-heart oxygen step-up, and treatment is stabilization bridging to emergent surgical closure.
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What this article covers
- Overview
Definition: ventricular septal rupture is post-infarction rupture of the interventricular septum creating a ventricular septal defect with an acute left-to-right shunt.
- Epidemiology
Rare and highly lethal, less common since routine reperfusion.
- Risk factors
Large transmural first infarct with delayed or absent reperfusion.
- Pathophysiology
Septal necrosis and rupture: infarcted septum ruptures, creating a defect.
- Clinical features
Abrupt hemodynamic collapse: hypotension and biventricular failure days after MI.
- Differential diagnosis
Papillary muscle rupture: acute mitral regurgitation with an apical murmur, large v waves, and no oxygen step-up, unlike the septal step-up here (mechanical complications of MI).
- Diagnosis
Establish with echocardiography showing the septal defect and shunt, confirmed by an oxygen step-up: the diagnostic basis is Doppler echocardiography demonstrating a ventricular septal defect with…
- Management
First, stabilize as a bridge to closure, continuing support until the operating room: Afterload reduction with sodium nitroprusside 0.3 mcg/kg/min IV, titrated, to reduce the shunt when blood pressure permits.
- Complications
Cardiogenic shock and multiorgan failure.
- Prognosis
Poor without surgery: medical therapy alone carries very high mortality.
- Prevention
Timely reperfusion of STEMI (primary PCI within 90 minutes) to limit infarct size.
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Related articles
- Mechanical complications of myocardial infarction
Mechanical complications of myocardial infarction are catastrophic structural ruptures, papillary muscle rupture, ventricular septal rupture, and free-wall rupture, occurring days after a usually large, late-reperfused infarct and presenting as abrupt hemodynamic collapse, often with a new murmur. Diagnosis is by urgent echocardiography, and survival depends on hemodynamic stabilization and emergent surgical repair.
- ST-elevation myocardial infarction (STEMI)
ST-elevation myocardial infarction is acute transmural myocardial ischemia from complete coronary occlusion, diagnosed by ischemic symptoms with diagnostic ST-segment elevation and a rising troponin. It is a time-critical emergency in which immediate reperfusion, primary PCI within 90 minutes or fibrinolysis when PCI is unavailable, plus antiplatelet and anticoagulant therapy, determines survival.
- Acute heart failure
Acute heart failure is the rapid onset or worsening of heart failure symptoms requiring urgent therapy, most often pulmonary congestion from a precipitant such as ischemia, arrhythmia, or nonadherence. Management is oxygen, intravenous diuretics, and vasodilators for the congested-but-perfused patient, with inotropes or support for the hypoperfused patient.
- Aortic dissection
Aortic dissection is a tear in the aortic intima allowing blood to split the media, creating a false lumen, and is a surgical emergency. Type A (ascending) dissection needs emergency surgery, while type B (descending) is usually managed medically with rapid heart-rate and blood-pressure control; the priority is impulse control with a beta-blocker first.