Image courtesy of Johannes W. Steyn, MD.

Image courtesy of Johannes W. Steyn, MD.

A 65-year-old man is diagnosed with an ST-segment elevation myocardial infarction and is treated with a coronary artery stent. Five days after stent placement, he develops acute-onset shortness of breath. A transesophageal echocardiogram is obtained. Which of the following is the MOST likely diagnosis?

  • □ (A) Ventricular septal defect

  • □ (B) Atrial septal defect

  • □ (C) Mitral stenosis

  • □ (D) Tricuspid stenosis

Ventricular septal rupture causing a ventricular septal defect is a well-known complication of acute myocardial infarction (AMI) (Figure). The introduction of thrombolytic therapy in the setting of AMI has reduced the incidence of post-AMI ventricular septal rupture from 2% to 0.2%. Ventricular septal rupture most commonly occurs in the first week after AMI.

Figure:

Transesophageal echocardiography for post-acute myocardial infarction ventricular septal defect, as indicated by the arrow. Image courtesy of Johannes W. Steyn, MD.

Figure:

Transesophageal echocardiography for post-acute myocardial infarction ventricular septal defect, as indicated by the arrow. Image courtesy of Johannes W. Steyn, MD.

Ventricular septal rupture leads to an acute left-to-right shunt and often precipitates cardiogenic shock. Urgent surgical repair has been the standard treatment for post-AMI ventricular septal defect (VSD), as the mortality rate for medical management approaches 90%. More recently, transcatheter repair of post-AMI VSD has been shown to be a viable option for treating smaller post-AMI VSDs.

AMI does not cause atrial septal rupture. Myocardial ischemia may lead to papillary muscle rupture and severe mitral regurgitation, but not mitral stenosis. AMI does not cause tricuspid stenosis.

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Bibliography

Bibliography
Gao
XM
White
DA
Dart
AM
Du
XJ
.
Post-infarct cardiac rupture: recent insights on pathogenesis and therapeutic interventions
.
Pharmacol Ther
.
2012
;
134
(
2
):
156
179
.
Maltais
S
Ibrahim
R
Basmadjian
AJ
et al
Postinfarction ventricular septal defects: towards a new treatment algorithm
.
Ann Thorac Surg
.
2009
;
87
(
3
):
687
692
.

Answer: A