Diagnostic accuracy of a novel ‘winking coronary angiographic sign’ in patients presenting with ventricular septal rupture complicating acute myocardial infarction

Ventricular septal rupture (VSR) is an uncommon but potentially lethal complication of acute myocardial infarction (MI). Its prompt recognition is essential to permit timely institution of corrective measures. The present study was undertaken to assess the diagnostic accuracy of a novel and unique angiographic sign, the ‘winking coronary sign (WCS)’, for recognizing post-MI VSR. The WCS is defined as partial transient occlusion of the infarct-related culprit artery overlying the site of VSR during ventricular systole with near normal filling in the diastole. A total of 56 patients with post-MI VSR (mean age 60.9 ± 9.9 years, 75% male) were compared with 73 age- and sex-matched acute MI patients without VSR. The extent of coronary artery disease was not different between the two groups, but higher number of patients in the VSR group had thrombolysis in MI grade 3 flow (57.1% vs 34.5%, P 0.01). The WCS was observed in 67.9% of the patients with VSR but in none of the patients without VSR (p < 0.0001), yielding a sensitivity of 67.9% and specificity of 100% for this sign for diagnosing underlying VSR. This demonstrates the potential utility of the WCS for diagnosing VSR in patients in whom the VSR has developed in the time frame between the echocardiography and angiography or has been missed during the initial clinical and/or echocardiographic evaluation.