Not all Postmyocardial Infarction Ventricular Septal Rupture Need Immediate Surgery: Role of Cardiogenic Shock Classification

A 56-year-old man presented with acute anterior ST elevation myocardial infarction. Initially he was thrombolysed at a peripheral hospital and a transthoracic echocardiography revealed multiple (2-3 mm) apical muscular ventricular septal defects suggesting ventricular septal rupture (VSR), with the largest measuring 10mm with left to right shunt and max gradient was 74 mmHg. His left ventricular ejection fraction was 45%. A coronary angiogram revealed tight proximal (95%) and mid segments (80%) stenosis in the left anterior descending artery (LAD) but diffusely diseased distally. Another significant stenosis (80%) was present at the ostium of the right posterior descending artery (r-PDA). He was in Society for Cardiovascular Angiography and Intervention (SCAI) cardiogenic shock Stage B, hence cardiac surgeons advised conservative medical treatment in order to stabilize the infarct area with view of good surgical outcome. Although, there was a dilemma between the surgeon and the cardiologist regarding timing VSR closure, classification of shock stages helped to delay surgery. Eventually, he was taken for surgery at the 18(th) day of admission with a graft to r-PDA rather to LAD (due to difficult visualization) and repair of VSR with Gortex patch. In conclusion, in all patients with post MI VSR, SCAI shock stages classification has to be applied in determining the timing of surgery.