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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • New loud holosystolic murmur days after an acute myocardial infarction (MI)

  • Sudden hypotension or heart failure after MI

  • Echocardiographic evidence of a ventricular septal defect (VSD)

GENERAL CONSIDERATIONS

  • Occurs in up to 3% of acute MIs

  • Half of the VSDs occur in anterior wall MI

  • This often occurs in the setting of first acute MI for the patient

  • Peak incidence is between 3 and 7 days

  • Acute mitral regurgitation secondary to acute MI has similar clinical presentation

  • The apical septum is affected in anterior MI and the basal septum in inferior MI

  • Complete heart block, atrial fibrillation, and bundle branch block are not infrequent in acute VSD

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Shortness of breath

  • Cardiogenic shock

PHYSICAL EXAM FINDINGS

  • Hypotension

  • New harsh, holosystolic murmur with a thrill

  • Elevated jugular venous pressure

DIFFERENTIAL DIAGNOSIS

  • Hypotension or heart failure with acute MI for other reasons

  • Acute mitral regurgitation due to papillary muscle rupture or dysfunction

  • Cardiac rupture with pseudoaneurysm formation

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC

  • Basal metabolic panel including serum creatinine (typically creatinine increases in shock secondary to poor renal blood flow)

  • Cardiac biomarkers

ELECTROCARDIOGRAPHY

  • ECG typically shows a transmural infarct

IMAGING STUDIES

  • Echocardiogram with color Doppler usually visualizes the defect, but occasionally it is difficult to see because it takes a circuitous course through the muscular interventricular septum

    • – Echo shows the septal wall motion abnormality and may show an enlarged right ventricle due to the left-to-right shunt

    • – Color Doppler is best for identifying the leak across the septum

    • – Pulsed or continuous-wave Doppler can quantify the gradient and estimate right ventricular pressure

DIAGNOSTIC PROCEDURES

  • Right heart catheterization identifies the oxygen step up in the right ventricle

  • Coronary arteriography to identify the extent of the coronary artery disease (CAD)

TREATMENT

CARDIOLOGY REFERRAL

  • All patients with suspected VSD after MI should be seen by a cardiologist

HOSPITALIZATION CRITERIA

  • All patients should be hospitalized to the cardiac intensive care unit

MEDICATIONS

  • Diuresis for heart failure

  • Pressor support for hypotension

  • IV sodium nitroprusside if blood pressure allows

THERAPEUTIC PROCEDURES

  • Percutaneous transcatheter devices can be used to close ventricular defects in selected patients

    Intra-aortic balloon pump may help stabilize the patient

SURGERY

  • Emergent corrective surgery with coronary artery bypass graft (CABG) as needed remains the gold standard

MONITORING
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