Atypical Presentation of Ventricular Septal Defect Following Myocardial Infarction

Atypical Presentation of Ventricular Septal Defect Following Myocardial Infarction Eduardo Cavalcanti Lapa Santos,1,2 Sandro Gonçalves Lima,1,2 Brivaldo Markman Filho,1,2 Andréa Bezerra de Melo da Silveira Lordsleem,1,2 George Augusto da Fonseca Carvalho Antunes Lima,1,2 Priscila Costa dos Santos Moreira1 Hospital das Clínicas UFPE (HC-UFPE);1 Universidade Federal de Pernambuco (UFPE),2 Recife, Pernambuco – Brazil


Introduction
Ventricular septal defect (VSD) is a rare complication of myocardial infarction (MI).The decrease in the incidence of this complication (1 to 2% in the pre-thrombolytic age to about 0,2% currently) has been attributed to the earlier and more effective treatment of MI.Patients typically present with a sudden onset hemodynamic impairment accompanied by a new heart murmur.Despite the advances of surgical assistance, mortality remains high (25 -87%).We report an atypical case of VSD following MI where the patient was olygosymptomatic and had the diagnosis weeks after the acute event.

Case Report
A 73-year-old male patient was admitted in the emergency department due to typical chest pain lasting approximately 30 minutes.He reported a history of systemic arterial hypertension.He was discharged from the hospital hours later without a confirmed diagnosis.Over the following weeks, he persisted with chest pain on moderade exertion, associated with dyspnea.Two months later, the patient was evaluated in an outpatient service where a regurgitative holosystolic murmur was heard on the left lower sternal border (3+/6+).The resting electrocardiogram showed left ventricular hypertrophy and negative and symmetrical T waves in lower leads.He was referred to our service where an echocardiogram revealed VSD in the basal portion of the inferior septal wall (Video 1) and an aneurysm in basal portion of the inferior wall.
Cardiac catheterization showed 3-vessel disease with an occluded right coronary artery (RCA).Ventriculography confirmed the VSD as well as the aneurysm of the basal portion of the lower wall (Video 2).
The patient was submitted to surgical correction of the VSD and resection of the aneurysm (Figure 1).Mammary bridge sequential to the diagonal branch and to the left anterior descendent artery was also performed.The patient had no postoperative complications.

Discussion
Ventricular septal defect (VSD) is a rare complication of myocardial infarction (MI). 1,2The reduced incidence of this complication (1 to 2% in the pre-thrombolytic age to about 0,2% currently) has been attributed to the earlier and more efficient management of MI. [3][4][5] The cases classically present with an abrupt onset of hemodynamic impairment accompanied by a new heart murmur. 6espite the advances of surgical assistance, mortality remains high (25 -87%). 7tients often have total coronary occlusion responsible for the ischemic event, suggesting that the mechanism involves a sudden and severe ischemic event, leading to extensive tissue necrosis. 4Reperfusion, especially if initiated early, is able to prevent myocardial necrosis that is typically associated with septal complications (40%). 3ctors associated with a higher risk of developing rupture of the interventricular septum after an acute ischemic event are listed in Table 1. 4,8e clinical presentation is usually marked by manifestations of hemodynamic instability: 9 cardiogenic shock, refractory pulmonary edema and the need for vasoactive drugs. 9In 90% of the cases, a new cardiac murmur can be detected. 6veral complementary methods can be used to diagnose VSD following MI: echocardiogram, cardiac catheterization, pulmonary artery catheterization, cardiography. 1,4The most commonly used method is echocardiography. 6e clinical management of post-myocardial infarction VSD includes medications and support devices such as intra-aortic balloon and are intended to reduce afterload and consequently reduce left-right shunt until surgical and/or definitive intervention. 5,9But it is noteworthy that VSD patients with in GUSTO-I selected for surgical repair had better results than those treated medically. 4On the other hand, those who advise against an early approach recommend to wait for the patient to recover and for the completion of the cicatricial process around the VSD. 3 The timing of repair of VSD after MI is still debatable. 3rrently, the percutaneous approach may be offered as a less invasive option for the immediate and long-term closure of the VSD. 3 Even with the advances of the surgical approach, interventricular septal repair in these cases remains a challenging surgical procedure associated with high early mortality. 5

Conclusion
Ventricular septal defect is a serious complication after MI, usually presenting with hemodynamic instability.We report

Figure 1 -
Figure 1 -Photograph of the aneurysm during VSD surgical correction with resection of the aneurysm.

Table 1 -
Factors associated with the development of post-acute myocardial infarction VSD (4on admissionFlow TIMI I and II in the culprit artery