Heartbreak: A case of post‐infarction cardiogenic shock

Abstract

Ventricular septal rupture is a rare but catastrophic complication of acute myocardial infarction. Although it has declined in incidence since the introduction of percutaneous coronary intervention, there hasn't been a significant change of mortality from the condition. In the chain of survival, prompt diagnosis and definitive surgery form the cardinal links. Prolonged medical management is not a feasible option as it is likely to be futile but the aim should be to reduce afterload with the help of intra-aortic balloon pump or support with ventricular assist devices. Echocardiography sits at the heart of the diagnosis of this time critical condition and will guide accurate therapy and intervention. We present the first reported case from an Australian emergency department, where the echocardiography done by the emergency physician clinched the diagnosis. We emphasise here the paramountcy of emergency physicians being proficient in basic echocardiography to achieve rapid diagnosis. Once diagnosed it is critical to have an individual case-tailored multi-disciplinary discussion between emergency medicine, cardiothoracic surgery, cardiology and intensive care as to plan the optimal timing of surgery.

A new dimension to the STEMI-related mortality risk seen in the COVID-19 pandemic era

“…Clinical and echocardiographic recognition of VSR coinciding with electrocardiographic recognition of STEMI ( Table 1 ). In this category there were 42 cases [ [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] ] (28 males) of mean age 67. The period of pre-hospital delay ranged from 6 h to 3 months.…”

“…Among 28 patients in whom a systolic murmur was actively sought the murmur was deemed to be present in 25. Two of the three patients in whom auscultation did not detect a murmur were hypotensive, with blood pressures of 90/56 mmHg [ 5 ] and 70/50 mmHg [ 8 ], respectively. In the third patient with undetectable murmur, no mention was made of blood pressure [ 12 ].…”

A Case Report: Point-of-care Ultrasound in the Diagnosis of Post-Myocardial Infarction Ventricular Septal Rupture

“…3 In the ED, POCUS shows promise as a rapid and easily accessible screening tool in the diagnosis of VSR, as well as other mechanical complications (e.g., RV wall rupture and aortic dissection). [4][5][6] Key sonographic findings of VSR include direct visualization of the defect, blood flow across the interventricular septum, and RV dilation. 7 Since the defect may not be visible in standard imaging planes, it is necessary to sweep through the interventricular septum and obtain non-standard windows.…”

“…7 Since the defect may not be visible in standard imaging planes, it is necessary to sweep through the interventricular septum and obtain non-standard windows. 5 Although standard echocardiographic evaluation is highly sensitive (90%) and specific (98%) for the diagnosis of VSR, 8 the test characteristics of POCUS are unknown, and likely depend on the size and position of the VSR and the ultrasound operator’s proficiency.…”