Correct!
5. All of the above

Both cardiology and thoracic surgery were consulted by thought that any intervention should be postponed because the post-MI myocardium would likely be too fragile for early intervention. Waiting 3-6 weeks was recommended to allow for scaring. In the meantime, supportive therapy was performed with afterload reduction, inotropes and vasopressors. Unfortunately, the patient decompensated and died.

Septal rupture resulting in a VSD after a myocardial infarction are unusual occurring in only 0.2% of patients (4). These usually occur within 3-5 days of the myocardial infarction. Our patient probably had a large infarction about 5 days before admission which would explain his relatively low troponins and his presentation with septal rupture.

Unfortunately, septal rupture can be an ominous sign. About 20% of patients also have concomitant rupture of the chordae tendineae resulting in mitral regurgitation (4). Mortality rates increase the longer a procedure to the VSD is delayed but the mortality from the procedure also declines with delay (5,6). In addition to medical therapy, mechanical support with an intra-aortic balloon pump or an Impella® device have been successfully used while supporting the patient until a definitive procedure can be performed (7,8).

References

  1. Ullman E, Brady WJ, Perron AD, Chan T, Mattu A. Electrocardiographic manifestations of pulmonary embolism. Am J Emerg Med. 2001 Oct;19(6):514-9. [CrossRef]  [PubMed]
  2. Crawford F, Andras A, Welch K, Sheares K, Keeling D, Chappell FM. D-dimer test for excluding the diagnosis of pulmonary embolism. Cochrane Database Syst Rev. 2016 Aug 5;(8):CD010864. [CrossRef] [PubMed]
  3. Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J. 2009 Feb;26(2):87-91. [CrossRef] [PubMed]
  4. Birnbaum Y, Fishbein MC, Blanche C, Siegel RJ. Ventricular septal rupture after acute myocardial infarction. N Engl J Med. 2002 Oct 31;347(18):1426-32. [CrossRef] [PubMed]
  5. Calvert PA, Cockburn J, Wynne D, et al. Percutaneous closure of postinfarction ventricular septal defect: in-hospital outcomes and long-term follow-up of UK experience. Circulation. 2014 Jun 10;129(23):2395-402. [CrossRef] [PubMed]
  6. Arnaoutakis GJ, Zhao Y, George TJ, Sciortino CM, McCarthy PM, Conte JV. Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database. Ann Thorac Surg. 2012 Aug;94(2):436-43; discussion 443-4. [CrossRef] [PubMed]
  7. Jones BM, Kapadia SR, Smedira NG, Robich M, Tuzcu EM, Menon V, Krishnaswamy A. Ventricular septal rupture complicating acute myocardial infarction: a contemporary review. Eur Heart J. 2014 Aug 14;35(31):2060-8. [CrossRef] [PubMed]
  8. Dahlin LG, Peterzén B. Impella used for hemostasis by left ventricular unloading, in a case with left ventricular posterior wall rupture. Ann Thorac Surg. 2008 Apr;85(4):1445-7. [CrossRef] [PubMed]

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