Management of ventricular septal rupture in acute myocardial infarction.

Abstract

suMMARY Four patients with rupture of the interventricular septum after myocardial infarction are described. This condition carries a grave prognosis. Surgical repair of the septum is almost always urgently required if the left-to-right shunt is large (QP/QS>3). Results are better if surgery can be deferred for six weeks to allow the infarcted area to heal and the tissues to become firmer. This delay may be achieved by using a combination of agents to reduce afterload and to exert a positive inotropic effect. The timing of surgical intervention was an important factor in the survival of three of the four patients.Ventricular septal defect after acute myocardial infarction was first described by Latham in 1846. hours of admission, complete heart block developed, preceded by sinus bradycardia and first and second degree atrioventricular block. The ventricular rate fell to 50/min and the blood pressure to 80/60 mmHg. Temporary atrioventricular sequential pacing was started. The blood pressure rose to 120/80 mmHg. Three days later sinus rhythm returned. The same day severe central chest pain recurred. The electrocardiogram showed sinus tachycardia at 120/min, with further ST segment elevation in leads II, III, and aVF. The blood pressure was 105/80 mmHg. The jugular venous pressure was raised with prominent 'a' and 'v' waves. A loud pansystolic murmur accompanied by a thrill was noted at the lower left sternal edge. A Swan-Ganz balloon tip catheter was inserted at the bedside. A large left-to-right shunt (QP/QS 4-8:1) was confirmed at ventricular level (Table 2). Systolic blood pressure had fallen to 65 mmHg. Digoxin and diuretics were started along with a dobutamine infusion. In view of the size of the shunt, persistent hypotension, and increasing congestive cardiac failure operation was carried out 10 hours after the development of the ventricular septal defect. At operation the right ventricle was greatly enlarged. The inferior surface of the heart was the site of a large haemorrhagic infarct covering most of the base and extending into the mitral annulus. The left ventricle was opened through its inferior surface using a longitudinal incision through the area of infarction parallel to the posterior descending coronary artery. The mitral apparatus and the papillary muscles appeared 570 on 10 May 2018 by guest. Protected by copyright.