Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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 ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.