2. Khalida parveen w/o Moula dad 55 yrKhalida parveen w/o Moula dad 55 yr
old, resident of Afzal Town, Khanewalold, resident of Afzal Town, Khanewal
presented to us in Emergencypresented to us in Emergency
department with complaint of :department with complaint of :
IntroductionIntroduction
4. History of presenting illnessHistory of presenting illness
My patient was alright 5 hour back whenMy 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
5. History of presenting illnessHistory of presenting illness
Associated with sweating and nausea butAssociated with sweating and nausea but
not associated with palpitations, shortnessnot 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.
6. Past HistoryPast History
There was no past history of suchThere was no past history of such
complaints.complaints.
No history of hospitalization due to anyNo history of hospitalization due to any
other cause.other cause.
7. Family HistoryFamily History
She has 2 brothers and 3 sisters , allShe has 2 brothers and 3 sisters , all
healthyhealthy
She has 2 sons and 3 daughters, allShe has 2 sons and 3 daughters, all
healthyhealthy
No history of any chronic illness in herNo history of any chronic illness in her
parents as wellparents as well
8. Personal HistoryPersonal History
She belongs to middle socioeconomicShe belongs to middle socioeconomic
status.status.
She is hypertensive for 10 years with poorShe 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 .
10. General Physical ExaminationGeneral Physical Examination
An old woman looking distressed , lying inAn 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 andwell-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
12. CardiovascularCardiovascular
System ExaminationSystem Examination
Pulse is 80/min,regular,normal volume ,normalPulse is 80/min,regular,normal volume ,normal
character,no radiofemoral delay,radial pulsescharacter,no radiofemoral delay,radial pulses
bilaterally equally palpable, vessel wall notbilaterally equally palpable, vessel wall not
palpable.palpable.
On inspection, shape of precordium is normal,noOn inspection, shape of precordium is normal,no
scar, no pulsationsscar, no pulsations
On palpation,apex beat is palpable in 5On palpation,apex beat is palpable in 5thth
intercostal space medial to mid-clavicular line, ofintercostal space medial to mid-clavicular line, of
normal character, no thrill,no left parasternalnormal character, no thrill,no left parasternal
heaveheave
On auscultation, both heart sounds are ofOn auscultation, both heart sounds are of
normal intensity,no added sound, no murmur .normal intensity,no added sound, no murmur .
13. RespiratoryRespiratory
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 movingprominent veins or pulsations visible. Chest is moving
equally on both sidesequally on both sides
On palpation, trachea is central, no tenderness orOn 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 bothChest expansion is 4 cm. vocal fremitus is equal on both
sidessides
On percussion, upper border of liver is in 5On percussion, upper border of liver is in 5thth
intercostalintercostal
space. Percussion note is resonant and equal on bothspace. Percussion note is resonant and equal on both
sidessides
On auscultation, breathing sounds are vesicular and ofOn auscultation, breathing sounds are vesicular and of
normal intensity. No added sounds.normal intensity. No added sounds.
14. GastrointestinalGastrointestinal
System ExaminationSystem Examination
On inspection,shape of abdomen is normal.On inspection,shape of abdomen is normal.
Abdomen is moving with respiration. UmbilicusAbdomen is moving with respiration. Umbilicus
is central and of normal shape. No pulsationsis 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 intact
On palpation, there is no rigidity or tendernessOn palpation, there is no rigidity or tenderness
on palpation. No viscera or mass palpableon palpation. No viscera or mass palpable
On percussion, there is no dullness or fluid thrillOn percussion, there is no dullness or fluid thrill
On auscultation, bowel sounds are 3-5 /min,ofOn auscultation, bowel sounds are 3-5 /min,of
normal intensity. No bruit sound audiblenormal intensity. No bruit sound audible
15. Cental NervousCental Nervous
System ExaminationSystem Examination
GCS 15/15GCS 15/15
Behavior is normal, no delusions/Behavior is normal, no delusions/
hallucinations. Memory is goodhallucinations. Memory is good
Speech is normalSpeech is normal
Cranial nerves are intactCranial nerves are intact
Sensory system is intactSensory system is intact
Motor system is intactMotor system is intact
No cerebellar signs foundNo cerebellar signs found
17. 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
19. 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 mmHg
Systolic thrill was palpable in 3Systolic thrill was palpable in 3rdrd
/4/4thth
intercostal spaceintercostal space
Cardiac auscultation revealed aCardiac auscultation revealed a
pan-systolic grade IV murmur, harsh in character, heardpan-systolic grade IV murmur, harsh in character, heard
all over the precordium with maximum intensity at leftall 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 Septalloud during expiration suggesting Ventricular Septal
Rupture after AWMI.Rupture after AWMI.
So inotropic support was started and Bed side ECHOSo inotropic support was started and Bed side ECHO
was done.was done.
21.
So our final diagnosis isSo our final diagnosis is ACUTEACUTE
Anterior wall M.I.Anterior wall M.I. complicated bycomplicated by
VSR.VSR.
22. PlanPlan
Plan was to surgically correct the defectPlan was to surgically correct the defect
so coronary angiography was planned.so coronary angiography was planned.
25. OverviewOverview
High mortality despite variousHigh mortality despite various
improvements in therapyimprovements in therapy
The mortality rate isThe mortality rate is
24% at 72 hours24% at 72 hours
75% at 3 weeks75% at 3 weeks
26. OverviewOverview
Relative Improvement in survival due toRelative Improvement in survival due to
Earlier diagnosisEarlier diagnosis
Earlier flow restorationEarlier flow restoration
More aggressive surgical interventionMore aggressive surgical intervention
27. OverviewOverview
Predictors of VSRPredictors of VSR
Advanced age,Advanced age,
Anterior location of infarction,Anterior location of infarction,
Female sexFemale sex
HTNHTN
28. OverviewOverview
Average time to ruptureAverage time to rupture
2-5 days2-5 days
Range: few hoursRange: few hours 2 weeks2 weeks
29. OverviewOverview
Coronary anatomy and VSRCoronary anatomy and VSR
Post MI VSRs more commonlyPost MI VSRs more commonly
associated with 100% occlusion of theassociated with 100% occlusion of the
infarct related arteryinfarct related artery
30. 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- mostremote from the primary septal defect- most
commonly an inferior VSRcommonly an inferior VSR
31. Anatomy of VSRsAnatomy of VSRs
Apical septal ruptureApical septal rupture
Comprise approximately 60-80% ofComprise approximately 60-80% of
casescases
LAD occlusion is always the culpritLAD occlusion is always the culprit
32. Anatomy of VSRsAnatomy of VSRs
Basal septal ruptureBasal septal rupture
Approximately 20-40% of casesApproximately 20-40% of cases
Occlusion ofOcclusion of
Dominant RCADominant RCA =>=> extensive RV infarctionextensive RV infarction
33. 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
34. 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
35. DiagnosisDiagnosis
Up to 50% of patients experience chestUp to 50% of patients experience chest
pain associated with the development ofpain associated with the development of
murmurmurmur
CHF and shock often associated with theCHF and shock often associated with the
development of murmurdevelopment of murmur
36. DiagnosisDiagnosis
Color Flow DopplerColor Flow Doppler
100% sensitive and specific in100% sensitive and specific in
differentiating VSR from acute MRdifferentiating VSR from acute MR
37. DiagnosisDiagnosis
Need for cardiac catheterizationNeed for cardiac catheterization
2/3 of the patients have multivessel coronary artery2/3 of the patients have multivessel coronary artery
diseasedisease
Cardiogenic shock not a hurdle to CatheterizationCardiogenic shock not a hurdle to Catheterization
=>=> Coronary angiographyCoronary 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.
38. ManagementManagement
Hemodynamically stable patients should haveHemodynamically stable patients should have
surgery on an urgent basis ( Class Isurgery 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.
39. ManagementManagement
Cardiogenic shock is associated with highCardiogenic shock is associated with high
surgical mortality , further supporting earliersurgical mortality , further supporting earlier
operations on these patients beforeoperations on these patients before
complications develop.complications develop.
Mortality in patients with cardiogenic shockMortality in patients with cardiogenic shock
and VSR was 81% ( SHOCK trial )and VSR was 81% ( SHOCK trial )
40. 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
41. 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.
