Rupture recurrence after surgical repair of a postinfarction ventricular septal rupture in the reperfusion era

Abstract

A 63-year-old male is admitted to the CCU for chest pain, shortness of breath, and an elevated troponin.The patient is a 63-year-old male with a past medical history significant for hypertension and hypercholesterolemia who presented to the emergency room with a chief complaint of shortness of breath and chest pain. The chest pain began two days prior and was associated with nausea. The patient proceeded to have increasing shortness of breath over the subsequent two days which brought him to the emergency room for evaluation.In the emergency room, the patient was noted to be in atrial fibrillation with rapid ventricular response and hypotension. He was cardioverted into sinus rhythm. The ECG showed sinus rhythm, RBBB and inferior myocardial infarction age indeterminate. The cardiac enzymes drawn in the emergency room showed a troponin of 30 ng/mL. The patient was transferred to the Coronary Care Unit. An echocardiogram performed in the Coronary Care Unit demonstrated a ventriculoseptal defect. The patient was emergently taken to the catheterization lab.The right heart catheterization demonstrated a mean right atrial pressure of 18 mmHg, right ventricular pressure of 42/18 mmHg, pulmonary pressure of 40/24 mmHg, and a pulmonary capillary wedge pressure of 23 mmHg. The right atrial oxygen saturation was 31% and the right ventricular oxygen saturation was 81%.The left ventriculogram demonstrated severe anterolateral hypokinesis and apical hypokinesis. There was evidence of dye exstravasation just superior to the anterolateral segment with late filling of the pulmonary artery suggesting a left to right shunt. Coronary arteriography demonstrated a 100% proximal occlusion of the left anterior descending artery after the first diagonal. The left circumflex artery had diffuse disease in the marginal system. The remaining vessels were angiographically normal.The patient was taken emergently to the operating room. Intraoperative transesophageal echocardiogram revealed a large ventricular septal defect in the apical portion of the septum located primarily anteriorly. The patient underwent coronary artery bypass grafting of the left internal mammary to the left anterior descending artery and the left radial artery to the first diagonal artery. The patient also received a bovine pericardial patch repair of the anterior apical VSD.The remainder of his hospital stay was unremarkable and he was discharged, however soon after discharge the patient began to develop progressively worsening shortness of breath requiring readmission to the hospital.Echocardiogram showed a large color flow turbulence moving across the septum consistent with a VSD. This was confirmed by cardiac MRI which showed a VSD between the left ventricle and