Ventricular septal rupture after an acute myocardial infarction is a life threatening
complication which carries a high mortality. Ventricular septal rupture results from full thickness infarction of
the interventricular septum followed by sufficient necrosis to result in the septal rupture. It is one of the three
mechanical complications that can occur following myocardial infarction. The others are free wall rupture, which
is usually rapidly fatal, and papillary muscle rupture, which results in sudden onset of mitral regurgitation. The
respective frequencies of these complications are in approximate proportion to the respective volumes of muscle
that are available to be involved, so that free wall rupture is most common, ventricular septal rupture next, and
papillary muscle rupture least.
The differential diagnosis of postinfarction cardiogenic shock should exclude VSR, free
ventricular wall rupture and rupture of the papillary muscles. In a recent report of the SHOCK (SHould
we emergently revascularize Occluded Coronaries for shocK) trial registry of 1160 patients with
cardiogenic shock 74.5% of patients had predominant left ventricular failure, 8.3% had acute mitral
regurgitation, 4.6% had ventricular septal rupture, 3.4% had isolated right ventricular shock, 1.7% had
tamponade or cardiac rupture, and 8% had shock that was a result of other causes. Cardiogenic shock is
most often associated with anterior myocardial infarction. In the SHOCK trial registry 55% of
infarctions were anterior, 46% were inferior, 21% were posterior, and 50% were in multiple locations.
Reperfusion therapy has reduced the incidence of septal rupture. The event occurs 2-8 days after an
infarction and often precipitates cardiogenic shock. Clinical studies report an average time of 2.6 days from
infarction to septal rupture. However, recent data suggest that the initial treatment of MI with thrombolytics may
affect both the time between infarction and septal rupture and outcome. The early use of thrombolytic agents
may lead to reopening of the occluded vessels, thus reducing the incidence of VSR. AIM OF THE STUDY:
This study aims at utilizing Real time three-dimensional transthoracic
echocardiography (RT3DE) technique for comprehensive assessment of
- location, size, shape of post myocardial infarction ventricular septal rupture.
- Pathomorphology of post myocardial infarction ventricular septal rupture.
- cardiac anatomy and cardiac pathophysiology after acute myocardial infarction.
- Clinical characteristics of patients with Acute myocardial infarction complicated by
ventricular septal rupture and its correlation with the findings of 3D echocardiography.
This study also aims to compare the findings between 2D TTE and Real time threedimensional
transthoracic echocardiography (RT3DE).
CONCLUSIONS:
1) Ventricular septal rupture complicates 1% of STEMI in our study population.Incidence of
VSR was common among female sex, elderly age group,hypertensive and among non
smokers.
2) Angina was absent in most cases of VSR in females .
3) All VSR cases were associated with first myocardial infarction.
4) VSR was common in AWMI than in IWMI.
5) Mortality was more in AWMI complicated by Ventricular septal rupture than in IWMI
complicated by VSR.
6) VSR was more commonly noted in delayed present cases and in patients not thrombolysed.
7) Cardiogenic shock was noted in most patients with VSR . With the onset of VSR 50 % of
patients were presented with cardiogenic shock, where as within 12 to 24 hours of onset of
VSR 86% were in cardiogenic shock.
8) Majority of cases presented with sinus Tachycardia and Hypotension.
9) 2D Echo could not visualize the site of defect without colour Doppler in 30 % cases.
10) 2D Echo could not Identify the Exact shape of VSR and complexity of lesion and also the
lesion extent.
11) 3D Echo imaging Identified the exact location of the VSR even prior to color Doppler and
shape of the lesion as elliptical, oval or irregular was identified from RV and LV aspects.
12)With live 3D Echo VSR was demonstrated in en face from Left ventricular and Right
ventricular side.
13) LV volume and EF was more accurate by 3D Echo, surface rendered method where as
LVEF by 2D Echo under estimate the LV volume and LVEF.
14) Single vessel lesion with total obstruction was the major CAG findings noted and no
collaterals noted during coronary angiogram
