Impact of cardiac magnetic resonance imaging in the management of post myo-cardial infarction ventricular septal rupture-a case report

Patel Tejas, Vinodrai Patelvinodraimohanbhai
A 61-year old man, a known diabetic and hypertensive, presented to us with worsening dyspnea of 25 days duration with pan-systolic murmur at left parasternal region without thrill. One month ago, he suffered from ST-segment elevation anterior wall myocardial infarc-tion with window period of 24 hours. He was taken up for coronary angiography and subsequently, balloon angioplasty with thrombosuction of the left anterior descending coronary artery was done. He developed sudden onset of dyspnea on
more » ... onset of dyspnea on the 5th day of admission which progressed to NYHA class III dyspnea when he presented to us. Echocardiogram showed 8 mm ventricular septal defect near apex with left to right shunt with moderate tricuspid regurgitation and pulmonary artery hypertension. Cardiac magnet resonance imaging was performed , which provided detailed information on size and localization of the ruptured septum as well as viability of myo-cardium. It showed thinning of the myo-cardium and ballooning in the left ven-tricular apical region with moderate left ventricular systolic dysfunction. There was defect in the interventricular septum at the apical region of 18 10 mm. Moreover, MRI revealed that the ventricular septal rupture was within the myocardial infarction area, which was substantially larger than the rupture. Severe hypokinesia and greater than 75 late gadolinium enhancement was present in the LAD territory (mid-distal septum and apical regions) suggestive of non-viable myocardium. Subsequently , patient underwent successful surgical closure of the defect (a Gore-Tex patch closure) along with saphenous ve-nous grafting to LAD. He was completely asymptomatic and in NYHA class I at 1 month of follow-up. Our case emphasizes the impact of cardiac magnetic resonance imaging in the management of such rare complication of acute myocardial infarction and its advantages over other imaging modalities. INTRODUCTION: Ventricular septal rupture (VSR) is a rare mechanical complication of acute myocardial infarction and associated with high mortality. Although the gold standard test for the diagnosis of VSR remains invasive ventriculogra-phy, echocardiography with color flow Dop-pler and cardiac magnetic resonance (CMR) are reliable non-invasive tests for the diagnosis. Our case illustrates the role of CMR for the complete delineation of this mechanical complication prior to surgical repair. CASE DETAILS A 61-year old man presented with complaints of dyspnea with exertion of 25 days duration. He denied any associated angina, palpitation or syncope. He was a known diabetic since past 10 years and known hypertensive since past 1 year. He was a non-smoker. On presentation to our hospital he was in NYHA class III symptoms. Clinically, harsh pan-systolic murmur (grade 3/6) at left paraster-nal region was present without any thrill. 1 month ago, he suffered from acute severe compressive chest pain with profuse sweating and subsequently admitted at local hospital after almost 24 hours of symptoms onset. He was diagnosed as acute ST-segment elevation anterior wall myocardial infarction. Subsequently, he underwent coronary an-giography which showed thrombotic occlu-sion of mid left anterior descending coronary artery (LAD) with normal other epicardial coronaries. Balloon angioplasty with mechanical thrombosuction of mid LAD was done. He was started on optimal medical management. On 5 th day after that episode, he developed shortness of breath which was rapidly progressive. His electrocardiogram showed poor R wave progression in chest leads with T wave inversion suggestive of fully evolved anterior wall myocardial infarc-tion (Figure 1). Chest x-ray showed mild car-diomegaly with increased pulmonary pleth-ora. There was