PresentorPresentor

Dr. Haseeb Raza NaqviDr. Haseeb Raza Naqvi

Khalida parveen w/o Moula dad 55 yr Khalida parveen w/o Moula dad 55 yr old, resident of Afzal Town, Khanewal old, resident of Afzal Town, Khanewal

presented to us in Emergency presented to us in Emergency

department with complaint of :department with complaint of :

IntroductionIntroduction

Presenting ComplaintPresenting Complaint

Chest pain -------------- 5 hoursChest pain -------------- 5 hours

History of presenting illnessHistory of presenting illness

My patient was alright 5 hour back when My patient was alright 5 hour back when she developed chest pain, she developed chest pain,

sudden in onset, sudden in onset,

severe in intensity, severe in intensity,

located centrally, located centrally,

non-radiating, non-radiating,

compressing in charactercompressing in character

History of presenting illnessHistory of presenting illness

Associated with sweating and nausea but Associated with sweating and nausea but not associated with palpitations, shortness not associated with palpitations, shortness of breath.of breath.

There was no history of fever , headache, There was no history of fever , headache, cough, hemoptysis, constipation, diarrhea, cough, hemoptysis, constipation, diarrhea, melena , polyuria, oliguria , dysuria, melena , polyuria, oliguria , dysuria, hematuria.hematuria.

Past HistoryPast History

There was no past history of such There was no past history of such complaints.complaints.

No history of hospitalization due to any No history of hospitalization due to any other cause.other cause.

Family HistoryFamily History

She has 2 brothers and 3 sisters , all She has 2 brothers and 3 sisters , all healthyhealthy

She has 2 sons and 3 daughters, all She has 2 sons and 3 daughters, all healthyhealthy

No history of any chronic illness in her No history of any chronic illness in her parents as wellparents as well

Personal HistoryPersonal History

She belongs to middle socioeconomic She belongs to middle socioeconomic status.status.

She is hypertensive for 10 years with poor She is hypertensive for 10 years with poor compliance.compliance.

No history of Smoking , D.M. ,T.B. , No history of Smoking , D.M. ,T.B. , Asthma , drug addiction or alcohol .Asthma , drug addiction or alcohol .

Occupational HistoryOccupational History

She is a house wife.She is a house wife.

General Physical ExaminationGeneral Physical Examination

An old woman looking distressed , lying in An old woman looking distressed , lying in bed with cannula attached to right hand , bed with cannula attached to right hand , well-oriented in time ,place and well-oriented in time ,place and person with following vitals :person with following vitals :

Pulse : 80/minPulse : 80/min

B.P. : 110/70 mm HgB.P. : 110/70 mm Hg

R.R. : 16/minR.R. : 16/min

Temperature : 98 FTemperature : 98 F

General Physical ExaminationGeneral Physical Examination

Pallor : -vePallor : -ve

Jaundice : -veJaundice : -ve

Cyanosis : -veCyanosis : -ve

Clubbing , Splinter hemorrhages : -veClubbing , Splinter hemorrhages : -ve

JVP : normalJVP : normal

Edema feet : -veEdema feet : -ve

Lymph nodes not palpableLymph nodes not palpable

Cardiovascular Cardiovascular System ExaminationSystem Examination

Pulse is 80/min,regular,normal volume ,normal Pulse is 80/min,regular,normal volume ,normal character,no radiofemoral delay,radial pulses character,no radiofemoral delay,radial pulses bilaterally equally palpable, vessel wall not bilaterally equally palpable, vessel wall not palpable.palpable.On inspection, shape of precordium is normal,no On inspection, shape of precordium is normal,no scar, no pulsationsscar, no pulsationsOn palpation,apex beat is palpable in 5On palpation,apex beat is palpable in 5 thth intercostal space medial to mid-clavicular line, of intercostal space medial to mid-clavicular line, of normal character, no thrill,no left parasternal normal character, no thrill,no left parasternal heaveheaveOn auscultation, both heart sounds are of On auscultation, both heart sounds are of normal intensity,no added sound, no murmur .normal intensity,no added sound, no murmur .

Respiratory Respiratory System ExaminationSystem Examination

On inspection, respiratory rate is 20/min, thoraco-On inspection, respiratory rate is 20/min, thoraco-abdominal . shape of chest is normal. no scar , abdominal . shape of chest is normal. no scar , prominent veins or pulsations visible. Chest is moving prominent veins or pulsations visible. Chest is moving equally on both sidesequally on both sidesOn palpation, trachea is central, no tenderness or On palpation, trachea is central, no tenderness or crepitus. Movement of chest is equal on both sides. crepitus. Movement of chest is equal on both sides. Chest expansion is 4 cm. vocal fremitus is equal on both Chest expansion is 4 cm. vocal fremitus is equal on both sidessidesOn percussion, upper border of liver is in 5On percussion, upper border of liver is in 5 thth intercostal intercostal space. Percussion note is resonant and equal on both space. Percussion note is resonant and equal on both sidessidesOn auscultation, breathing sounds are vesicular and of On auscultation, breathing sounds are vesicular and of normal intensity. No added sounds.normal intensity. No added sounds.

GastrointestinalGastrointestinalSystem ExaminationSystem Examination

On inspection,shape of abdomen is normal. On inspection,shape of abdomen is normal. Abdomen is moving with respiration. Umbilicus Abdomen is moving with respiration. Umbilicus is central and of normal shape. No pulsations is central and of normal shape. No pulsations are visible. No scar mark,striae,prominent veins. are visible. No scar mark,striae,prominent veins. Hernial orifices are intactHernial orifices are intactOn palpation, there is no rigidity or tenderness On palpation, there is no rigidity or tenderness on palpation. No viscera or mass palpableon palpation. No viscera or mass palpableOn percussion, there is no dullness or fluid thrillOn percussion, there is no dullness or fluid thrillOn auscultation, bowel sounds are 3-5 /min,of On auscultation, bowel sounds are 3-5 /min,of normal intensity. No bruit sound audiblenormal intensity. No bruit sound audible

Cental Nervous Cental Nervous System ExaminationSystem Examination

GCS 15/15GCS 15/15Behavior is normal, no delusions/ Behavior is normal, no delusions/ hallucinations. Memory is goodhallucinations. Memory is goodSpeech is normalSpeech is normalCranial nerves are intactCranial nerves are intactSensory system is intactSensory system is intactMotor system is intactMotor system is intactNo cerebellar signs foundNo cerebellar signs found

ECG ECG

Patient was treated on the line of Acute Anterior wall M.I. and thrombolyzed by streptokinase.Blood samples were drawn and send for CBC, Cardiac Enzymes ,RPM, RBS ,S/E

LABSLABS

After 2 daysAfter 2 days

The patient started to become short of breath.The patient started to become short of breath.Her B.P. dropped from 110/70 to 90/60 mmHgHer B.P. dropped from 110/70 to 90/60 mmHgSystolic thrill was palpable in 3Systolic thrill was palpable in 3 rdrd/4/4thth intercostal space intercostal spaceCardiac auscultation revealed a Cardiac auscultation revealed a pan-systolic grade IV murmur, harsh in character, heard pan-systolic grade IV murmur, harsh in character, heard all over the precordium with maximum intensity at left all over the precordium with maximum intensity at left lower sternal border, radiating to right side of sternum, lower sternal border, radiating to right side of sternum, loud during expiration suggesting Ventricular Septal loud during expiration suggesting Ventricular Septal Rupture after AWMI.Rupture after AWMI.So inotropic support was started and Bed side ECHO So inotropic support was started and Bed side ECHO was done.was done.

ECHOECHO

So our final diagnosis is So our final diagnosis is ACUTE ACUTE Anterior wall M.I.Anterior wall M.I. complicated by complicated by

VSR.VSR.

PlanPlan

Plan was to surgically correct the defect Plan was to surgically correct the defect so coronary angiography was planned.so coronary angiography was planned.

Post MI Ventricular Post MI Ventricular Septal Rupture:Septal Rupture:

OverviewOverview

VSR Complicates 1-2% of cases of VSR Complicates 1-2% of cases of acute myocardial infarction.acute myocardial infarction.

OverviewOverview

High mortality despite various High mortality despite various improvements in therapyimprovements in therapy

The mortality rate isThe mortality rate is 24% at 72 hours 24% at 72 hours 75% at 3 weeks 75% at 3 weeks

OverviewOverview

Relative Improvement in survival due toRelative Improvement in survival due to

Earlier diagnosisEarlier diagnosis Earlier flow restoration Earlier flow restoration More aggressive surgical interventionMore aggressive surgical intervention

OverviewOverview

Predictors of VSRPredictors of VSR Advanced age,Advanced age, Anterior location of infarction,Anterior location of infarction, Female sexFemale sex HTNHTN

OverviewOverview

Average time to ruptureAverage time to rupture 2-5 days2-5 days

Range: few hours Range: few hours 2 weeks 2 weeks

OverviewOverview

Coronary anatomy and VSRCoronary anatomy and VSR

Post MI VSRs more commonly Post MI VSRs more commonly associated with 100% occlusion of the associated with 100% occlusion of the infarct related arteryinfarct related artery

Anatomy of VSRsAnatomy of VSRs

Two types of VSRTwo types of VSR

SimpleSimple: through and through defect usually : through and through defect usually located anteriorlylocated anteriorly

ComplexComplex: serpentiginous dissection tract : serpentiginous dissection tract remote from the primary septal defect- most remote from the primary septal defect- most commonly an inferior VSRcommonly an inferior VSR

Anatomy of VSRsAnatomy of VSRs

Apical septal ruptureApical septal rupture

Comprise approximately 60-80% of Comprise approximately 60-80% of casescases

LAD occlusion is always the culpritLAD occlusion is always the culprit

Anatomy of VSRsAnatomy of VSRs

Basal septal ruptureBasal septal rupture Approximately 20-40% of casesApproximately 20-40% of cases Occlusion of Occlusion of

Dominant RCA Dominant RCA =>=> extensive RV infarction extensive RV infarction

Anatomy of VSRsAnatomy of VSRs

Multiple defects (5-11% of cases)Multiple defects (5-11% of cases)

Secondary to infarct extensionSecondary to infarct extension Evolve within days of each otherEvolve within days of each other

DiagnosisDiagnosis

Loud/harsh pansystolic murmurLoud/harsh pansystolic murmur

Within the first week post AMIWithin the first week post AMI Best heard at Lt. Lower sternal borderBest heard at Lt. Lower sternal border Less loud at the apexLess loud at the apex Associated with a thrillAssociated with a thrill

DiagnosisDiagnosis

Up to 50% of patients experience chest Up to 50% of patients experience chest pain associated with the development of pain associated with the development of murmurmurmur

CHF and shock often associated with the CHF and shock often associated with the development of murmurdevelopment of murmur

DiagnosisDiagnosis

Color Flow DopplerColor Flow Doppler

100% sensitive and specific in 100% sensitive and specific in differentiating VSR from acute MRdifferentiating VSR from acute MR

DiagnosisDiagnosis

Need for cardiac catheterizationNeed for cardiac catheterization2/3 of the patients have multivessel coronary artery 2/3 of the patients have multivessel coronary artery

diseasediseaseCardiogenic shock not a hurdle to CatheterizationCardiogenic shock not a hurdle to Catheterization

=>=> Coronary angiography Coronary angiography should be performedshould be performed

VSR demonstrate a “step up” in oxygen saturation in blood samples from the right ventricle and pulmonary artery compared with those from the right atrium.

ManagementManagement

Hemodynamically stable patients should have Hemodynamically stable patients should have surgery on an urgent basis ( Class I surgery on an urgent basis ( Class I recommendation)recommendation)

In patients who are hemodynamically unstable, the circulation should at first be supported by intra-aortic balloon pulsation and a positive inotropic agent such as dopamine or dobutamine . IABP should be inserted as early as possible as a bridge to a surgical procedure.

ManagementManagement

Cardiogenic shock is associated with high Cardiogenic shock is associated with high surgical mortality , further supporting earlier surgical mortality , further supporting earlier operations on these patients before operations on these patients before complications develop.complications develop.

Mortality in patients with cardiogenic shock Mortality in patients with cardiogenic shock and VSR was 81% ( SHOCK trial )and VSR was 81% ( SHOCK trial )

Percutaneous therapyPercutaneous therapy

Percutaneous closure of a post-MI VSR as a bridge to surgery is a therapeutic option in patients with high surgical risk, allowing hemodynamic stabilization and thus gaining time for a further surgical intervention if needed, improving patients prognosis

Urgent Hybrid ApproachUrgent Hybrid Approach

In selected cases, with high operative risk and unstable hemodynamic state due to AMI complicated by VSR, urgent hybrid approach consisting of the initial PCI followed by surgical closure of VSR may represent an acceptable treatment option and contribute to the treatment of this complex group of patients.

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