Images in Clinical Medicine

Ventricular Septal Rupture after Myocardial Infarction

Duane S. Pinto, M.D., and Thomas M. Tu, M.D.

N Engl J Med 2002; 347:1334October 24, 2002

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Left Ventriculography.

Figure 1 Chest pain and diaphoresis developed in an 81-year-old woman with chronic renal insufficiency and hypertension. Although the chest pain resolved, she saw her primary care physician three days later because of profound fatigue. She had a loud holosystolic murmur on physical examination. A 12-lead electrocardiogram demonstrated ST-segment elevation and Q waves in leads II, III, and aVF. The creatine kinase level was 274 U per liter, with an MB fraction of 23 U per liter, and the cardiac troponin I level was more than 50 ng per milliliter. Cardiac catheterization revealed critical single-vessel disease of the right coronary artery without collateral-vessel supply. Right anterior oblique left ventriculography (Panel A) and left anterior oblique left ventriculography (Panel B and video clip, available with the full text of this article at http://www.nejm.org) demonstrated that contrast medium was flowing from the left ventricle (LV) to the right ventricle (RV) through a perforation in the inferoapical ventricular septum (VSP, arrow). The right atrium (RA) and pulmonary artery (PA) are also visible in Panels A and B. The patient underwent coronary-artery bypass grafting and operative repair of the rupture. On the second postoperative day, cardiac arrest occurred. Bedside thoracotomy revealed rupture of the left ventricular free wall, and resuscitative measures were unsuccessful.

Duane S. Pinto, M.D.
Thomas M. Tu, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215