|Year : 2015 | Volume
| Issue : 1 | Page : 24-26
A Case of Acquired Ventricular Septal Defect Complicating Silent Myocardial Infarction: An Unusual Presentation
Neelima Singh, Ram K Gupta, Manish K Multani, Sandeep Singh
Department of Medicine, G.R. Medical College, Gwalior, Madhya Pradesh, India
|Date of Web Publication||14-Mar-2015|
Dal Bazar, Tiraha, Lashkar, Gwalior - 474 009, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Ventricular septal defect (VSD) is a rare, but serious complication of acute myocardial infarction requiring early surgical intervention. We report a case of a 75-year-old man, who had a silent myocardial infarction followed by an asymptomatic ventricular septal rupture, both of which remained undiagnosed until the patient experienced biventricular failure. Asymptomatic myocardial infarction in elderly may be a risk factor for acquired VSD. Two-dimensional echocardiography is a sensitive, rapid, reliable and safe technique for diagnosing VSD postmyocardial infarction.
Keywords: Biventricular failure, myocardial infarction, ventricular septal defe
|How to cite this article:|
Singh N, Gupta RK, Multani MK, Singh S. A Case of Acquired Ventricular Septal Defect Complicating Silent Myocardial Infarction: An Unusual Presentation. Heart India 2015;3:24-6
|How to cite this URL:|
Singh N, Gupta RK, Multani MK, Singh S. A Case of Acquired Ventricular Septal Defect Complicating Silent Myocardial Infarction: An Unusual Presentation. Heart India [serial online] 2015 [cited 2020 May 28];3:24-6. Available from: http://www.heartindia.net/text.asp?2015/3/1/24/153283
| Introduction|| |
Acquired ventricular septal defect (VSD) is one of the three major mechanical complications of acute myocardial infarction (AMI), the other two being acute mitral regurgitation and rupture of the ventricular free wall. Complications of AMI have decreased in number and severity in recent years due to of early thrombolytic or coronary revascularization techniques. 
Postinfarction VSD is an acute emergency which carries a very high mortality. Appropriate early intervention, however, can significantly increase the survival rate. Despite improvements in medical therapy and percutaneous and surgical techniques, mortality with this complication remains extremely high.  Spontaneous closure is extremely rare. ,
Diagnosis is now achieved reliably and noninvasively with Doppler transthoracic echocardiography. Transesophageal echocardiography may be occasionally necessary in the case of inferior infarction to establish the extent of the defect. Decision on terms of surgical intervention should be individualized. Early surgical closure is the treatment of choice, even if the patient's condition is stable.  Without a rapid diagnosis and correction by surgical intervention, the short-term mortality of these patients is higher than 90%. 
| Case report|| |
A 75-year-old previously healthy male presented to the emergency department complaining of palpitation and difficulty in breathing for the last 8 days. The patient had no history of cardiovascular illness. He was in respiratory distress with a respiratory rate of 28/min, heart rate of 108/min and a blood pressure of 104/64 mm Hg. The jugular venous pressure was raised and on palpation there was 4/6 pansystolic murmur across the precordium with a thrill. Auscultatory examination revealed bilateral coarse crepitations at the base of the lungs. The skiagram of the chest was suggestive of cardiomegaly. The electrocardiogram [Figure 1] showed sinus tachycardia with left atrial overload, qs pattern and ST elevation in septal leads. Troponin-T was negative. Two-dimensional echocardiography showed drop in the distal interventricular septum along with turbulent flow with a gradient of 51 mm across the defect in the right ventricle [Figure 2]. VSD in distal third of the interventricular septum measured 6 mm in size [Figure 3]. Left ventricle was dilated with thinned septum [Figure 4]. Ejection fraction was 42%. Both right ventricle and right atrium were dilated, and tricuspid regurgitation was present.
|Figure 1: Sinus tachycardia with left atrial overload, qs pattern and ST elevation in septal leads|
Click here to view
|Figure 3: Image shows dropout of 6 mm in lower one-third of the ventricular septum|
Click here to view
His condition improved with decongestive measures from New York Heart Association (NYHA) class III to NYHA class II and he remained hemodynamically stable. He was placed on regular therapy with anti-ischemics, antiplatelets and diuretics and was discharged from the hospital after 6 days in stable condition. He was asked to attend higher center for appropriate interventions as we did not have the facility for angiography and cardiothoracic surgery.
| Discussion|| |
This case highlights classic features of ventricular septal rupture complicating asymptomatic myocardial infarction. Risk factors for acquired VSD include age, hypertension, lack of thrombolysis and collaterals.  Cardiogenic shock is the usual presentation in AMI, but this patient presented with biventricular failure and was hemodynamically stable at presentation probably due to silent myocardial infarction in the past associated with small sized defect in the interventricular septum. The typical pansystolic murmur across the precordium with a thrill raised suspicion of VSD, which was confirmed by two-dimensional echocardiography. Such unrecognized acquired ventricular septal rupture will run a downhill course unless intervened. Early diagnosis and surgical intervention are essential to improve survival.
| Conclusion|| |
Asymptomatic myocardial infarction in elderly may be a risk factor for acquired VSD. Two-dimensional echocardiography is a sensitive, rapid, reliable and safe technique for diagnosing VSD postmyocardial infarction.
| References|| |
Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, et al.
Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27-32.
Donoiu I, Istratoaie O, Ionescu DD. Ventricular septal rupture after acute myocardial infarction. Hellenic J Cardiol 2010;51:374-6.
Williams RI, Ramsey MW. Spontaneous closure of an acquired ventricular septal defect. Postgrad Med J 2002;78:425-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]