Laxman Dubey1*, Ridhi Adhikari2, Sogunuru Guruprasad3 and Gangapatnam Subramanyam3
1Associate Professor, Department of Cardiology, College of Medical Sciences & Teaching Hospital, Bharatpur, Nepal
2Lecturer, Department of Radiodiagnosis, College of Medical Sciences & Teaching Hospital, Bharatpur, Nepal
3Professor, Department of Cardiology, College of Medical Sciences & Teaching Hospital, Bharatpur, Nepal
Received: 17 March, 2017; Accepted: 28 March, 2017; Published: 30 March, 2017
Laxman Dubey, Doctor, MD, DM, Associate Professor, Department of Cardiology, College of Medical Sciences & Teaching Hospital, Bharatpur, Nepal, E-mail:
Laxman D, Adhikari R, Guruprasad S, Subramanyam G (2017) Ventricular Septal Rupture Complicating Acute Myocardial Infarction in a Tertiary Care Hospital of Nepal. J Cardiovasc Med Cardiol 4(1): 013-016. 10.17352/2455-2976.000040
© 2017 Laxman D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Background: Ventricular septal rupture is a rare but fatal mechanical complication of acute myocardial infarction. Although the incidence has decreased, the mortality rate from ventricular septal rupture has remained extremely high.
Objectives: The aim of this study was to assess the patient with acute myocardial infarction complicating with ventricular septal rupture and to identify the risk factors for ventricular septal rupture in a tertiary level hospital of Nepal.
Patients and Methods: This is a retrospective analysis of 11 patients who were diagnosed as ventricular septal rupture complicating acute myocardial infarction in College of Medical Sciences & Teaching Hospital, Bharatpur, Nepal.
Results: All (100%) patients were female with mean age of 65.8±9.3 years. Three patients (27.3%) were smokers, seven (63.6%) were hypertensive, and four (36.4%) were diabetic. None of our patients had previous history of coronary artery disease. Nine (81.8%) patients had ventricular septal rupture in apical septum and two (18.2%) in basal septum. Since there was no backup cardiac surgery facility available in our hospital, all patients were managed conservatively. In-hospital mortality was 90.9%.
Conclusions: Ventricular septal rupture following acute myocardial infarction has very high in-hospital mortality and is more common in female patients with no previous history of coronary artery disease. Rupture in apical septum is more common than basal septum rupture.
Ventricular septal rupture (VSR) is a rare but fatal complication of acute myocardial infarction (AMI). VSR was first described by Latham first at autopsy in 1847 . However, first ante-mortem diagnosis of post MI VSR was made by Brunn in the year 1923 . In the pre-fibrinolytic era, the incidence of VSR was 1-2%, however, reperfusion therapy has decreased the incidence of VSR which is now amounted to 0.2% [3,4].
Despite decreasing incidence, the mortality rate from VSR has remained extremely high. When conservative treatment is applied alone, the mortality rate reaches 90-95%, while for surgical intervention it varies from 19% to 60% . Therefore, current guidelines from the American College of Cardiology Foundation and American Heart Association (ACCF/AHA) recommend emergent surgical repair regardless of hemodynamic stability at the time of diagnosis .
This study was aimed to assess the patient with AMI complicating with VSR and to identify the risk factors for VSR in a tertiary level hospital of Nepal.
Patients and Methods
A retrospective data analysis was performed on 11 patients diagnosed as VSR following AMI who presented or referred to College of Medical Sciences & Teaching Hospital (CMS-TH) till June 2016. Seven patients were referred from outside and 4 visited to our emergency room directly. The AMI diagnosis was based on clinical ischemic symptoms, electrocardiographic changes, and/or positive levels of biomarkers of myocardial necrosis. VSR was diagnosed in CMS-TH by transthoracic echocardiography. Baseline patient characteristics, clinical characteristics upon admission, coronary interventions, location of coronary artery lesion, left ventricular ejection fraction, location of ventricular septal defect and in-hospital mortality were analyzed. Ethical committee had approved for the study. Standard statistical software SPSS (version 20 for Windows) was used for calculations. Quantitative variables are presented as mean ± standard deviation. Categorical variables are presented as both absolute and relative (%) values.
A total 11 patients were diagnosed as VSR complicating AMI. Interestingly all (100%) patients were female. Mean age was 65.8±9.3 years. Previous history of coronary artery disease (CAD) was absent in all cases. 27.3% were smokers, 63.6% were hypertensive and 36.4% of patients were diabetic. On arrival to our hospital, 72.7% of the patients were in Killip class IV. Baseline characteristics are shown in table 1.
Coronary angiography was performed in three patients. Two patients had single vessel disease (SVD) and one had triple vessel disease (TVD). Culprit vessel was the left anterior descending (LAD) artery in 66.7% cases and the right coronary artery (RCA) in 33.3% cases. One patient underwent primary PCI and stenting to the LAD who was diagnosed to have VSR after stenting.
Transthoracic echocardiography was performed to diagnose VSR. Mean left ventricular ejection fraction (LVEF) was 45.7±4.5%. VSR was seen as a defect in interventricular septum with significant flow between the chambers. Regarding the location of the VSR, nine (81.8%) patients had VSR in apical septum. These patients presented with acute anterior wall MI. Rest two (18.2%) patients had VSR in basal septum [Figures 1,2].
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