Ventricular septal defect after myocardial infarction: diagnosis by two-dimensional contrast echocardiography.

Abstract

SUMMARY Thirteen patients who had ventricular septal defects (VSDs) after myocardial infarction (MI) underwent two-dimensional echocardiography (2-D echo), with confirmation of the VSD by oximetry. Eight of the patients were male and five were female, ages 51-76 years. Five had anterior and eight inferior MIs. Two-dimensional echocardiography revealed akinesis or dyskinesis of the interventricular septum (IVS) in all 13 patients. In only six could a defect in the IVS be directly visualized. Two-dimensional echocardiographic left ventricular (LV) wall motion abnormalities correlated with ECG and angiographic site of infarction in all patients. Twelve patients had adequate saline contrast studies. Positive LV contrast (microbubbles entering the left ventricle through the VSD) was seen in 11 patients, and negative right ventricular (RV) contrast (washout of the RV bubbles by LV blood crossing the VSD) in five patients; at least one abnormality was present in every patient. The location of the VSD was determined by visualizing a VSD or by the site of the positive LVor negative RV contrast. Oximetry showed VSD shunts of 1.4:1 to 7:1, with no correlation between the degree of negative RV contrast and shunt size. Surgical or pathologic confirmation of VSD was obtained in 12 patients, with agreement of VSD location by 2-D echo in all. Four of the 11 patients who underwent surgical repair died, and two patients died before surgery could be attempted. We conclude that 2-D echo is a sensitive, rapid and safe technique for diagnosing VSD after MI. Positive LV contrast, with or without negative RV contrast, is more sensitive in the diagnosis and localization of post-MI VSD than direct echocardiographic visualization of the defect.

Murmur in a 62-Year-Old Man After Inferior Wall Myocardial Infarction

“…Worsening dyspnea after acute inferior wall myocardial infarction (MI) should raise concern for a mechanical complication after MI, including papillary muscle injury, ischemic mitral regurgitation, and interventricular septal rupture. 1,2 Although routine TTE usually provides a definitive diagnosis, [1][2][3] an extremely inferiorly located VSD could be missed by bedside and limited echocardiography without specific protocols or maneuvers. 3 With special attention to this patient's symptoms and murmur (point-of-care information), echocardiography with a modified view and adjusted protocols was performed to diagnose VSD (Videos 5-8), resulting in the surgical treatment.…”

Post Myocardial Infarction Ventricular Septal Defect

“…Echocardiography is a fundamental imaging modality, as it is noninvasive and easily accessible, allowing for rapid diagnosis [7,9,13,14]. Diagnosis from echocardiogram is largely from saline contrast visualization and doppler imaging rather than direct visualization [7], however, the limitations of echocardiography is the underestimation of the size of the VSD [15]. Further diagnosis studies include catheterization, both of the right and left heart and cardiac magnetic resonance imaging [9].…”

“…The definitive management for an acquired VSD is surgical closure of the VSD [9,14,15]. There is an increased risk of mortality with a reduced rupture to surgery time secondary to the friability of the damaged tissue as mortality is the greatest immediately after rupture.…”

“…Stabilization with an intraaortic balloon pump is often used to augment coronary perfusion and end-organ perfusion from improved cardiac output to delay surgical intervention [9,13]. The idea behind medically treating cardiogenic shock is to allow time for the necrotic myocardium to have increased scarred tissue and fibrosis for a more secured repair; acutely injured myocardium has increased friability and is less likely to be able to hold a suture [8,9,15]. In conclusion, post MI VSDs are catastrophic complications with a high mortality despite current advances.…”

Echocardiography: current status and future prospects

“…Among sites of rupture, free wall rupture is still usually fatal but ventricular septal rupture and papillar muscle rupture can be treated surgically. Drobac et al (26), reviewed the use of two-dimensional contrast echocardiography in 13 patients with oximetry confirmed post infarction VSD and concluded this approach allowed rapid and reliable diagnosis. Another complication, left ventricular thrombus is easily diagnosed by echocardiography and often presents a dramatic picture.…”