Management of Post Infarction Ventricular Septal Rupture in Contemporary Era

INTRODUCTION: During the COVID-19 pandemic, there has been an increase in mortality and complications following STEMI. The rarity of ventricular septal rupture (VSR) in the age of primary percutaneous coronary intervention has resulted in a lack of expertise in its management. Our strategy has been to stabilize patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) then evaluate for surgical repair with revascularization as well as advanced options, such as heart transplantation. Here we present two cases. CASE 1: A 65-year-old man with a history of hypertension presented to the hospital with an inferior STEMI and cardiogenic shock. He was found to have acute occlusion of the right coronary artery (RCA) through which a wire was not able to be passed. He also had severe disease in the left anterior descending artery (LAD) and left circumflex artery (LCx). An intra-aortic balloon pump (IABP) was placed. On hospital day 6, hemodynamics worsened and he was found to have a large VSR of the basal inferoseptum and biventricular dysfunction with a left ventricular ejection fraction (LVEF) of 10-15%. He was placed emergently on VA ECMO. Ten days later, he underwent repair of VSR and coronary artery bypass grafting (CABG) with a left internal mammary artery (LIMA) to LAD, and saphenous vein graft to an obtuse marginal. He underwent ECMO decannulation on post operative day 6. He was discharged home on post operative day 23 on medical therapy with an LVEF of 35%. He remains on medical therapy at 6 months. CASE 2: A 43-year-old man with a history of hypertension and diabetes suffered an inferoposterior STEMI. Coronary angiography showed acute occlusion of the RCA. He underwent thrombectomy and placement of two bare metal stents with no reflow, and placement of an IABP. He also had chronic occlusion of the LCx and 80% stenosis in the proximal LAD. A post procedure echocardiogram showed LVEF of 35-40%, severe right ventricular dysfunction, and VSR in the mid inferoseptum. He had worsening cardiogenic shock and underwent VA ECMO placement. On hospital day 9, he underwent VSR repair and single vessel CABG with LIMA to LAD. Due to inability to wean off bypass, he required placement of dual-pump biventricular support with Centrimag pumps after which he had persistent ventricular tachycardia. He was listed status 1A and underwent successful heart transplantation on hospital day 20. He is doing well at follow up. SUMMARY: We presented two cases of ventricular septal rupture complicating myocardial infarction, both with successful outcomes. During the COVID-19 pandemic, clinicians will need to maintain a high index of suspicion of mechanical complications of late presenting STEMI.