Ventricular septal rupture is one of the most lethal complication of myocardial infoarction with mortality rate upto 42.4% even after so much advancement in critical care and revascularisation therapy. The management of VSR is depends upon the hemodynamic stability of the patient.

1. Post-MI Ventricular Septal Rupture- Case
Presentation
DR V.K. CHAUDHARY
CTVS RESIDENT(SCTIMST)
MBBS, MS, DNB, MCLS

2. DEMOGRAPHY
o 42 Y/F
o DM X 6months
o DLP X 6months
o No Previous History
Of ACS
o No Other
Comorbidities

3. HOPI
• Chest pain since 2:00 PM 3/1/2026
• Nearby hospital- ECG done- symptomatic management
• Returned to home
• Persistent chest pain with extreme fatiguability and restlessness- Royal
Health Centre
• ECG- STE in V1-V5, Trop I-18.32
• Loading dose of Aspirin/Clopilet/Atorvas given and referred
Asymptoma
tic
Typical/atypical chest
pain
Pulmonary
oedema/hypotension/shock
Sudden cardiac
death

5. ASSESSMENT AT THE HIGHER CENTER
• Medtrina Hospital
• ECHO- showed VSR
• Loading dose of Ticagrelor -180mg given
• Started on Noradrenaline
• Stabilised and referred to SCT

7. AT SCT-
o GC- Sick on Noradrenaline support
o Cold Peripheries
o PR-120/min, BP-114/84, RR-30/min
o R/S- B/L Coarse Crepts
o Pan-systolic Murmur At LLSB

8. ECG
120/Min, STE- V2-V5 And AvL,

9. X-RAY

10. TTE

11. TTE
• LV-51/40
• IVS- 8/7
• EF-30%
• LA-31
• AO-29
• RWMA- AL/AW/Apex- Akinetic
• Apical VSR-4mm with L-R shunt (multiple fenestration
present), gradient-60mmHg
• Moderate RV dysfunction (TAPSE-11)
• MR 2+
• Moderate- severe LV Dysfunction

12. WHEN TO INTERVENE

13. CAG

14. X-RAY

15. PRE-OP DIAGNOSIS
CAD, DVD, P/POBA (LAD), APICAL VSR, LV APICAL
ANEURYSM, MOD BIVENTRICULAR DYSFUNCTION,
MILD MR, MILD TR, SR, DM, HTN, DLP
Procedure Plan
VSR REPAIR + CABG X 2G

16. o Recent MI with cardiogenic shock
o Moderate Biventricular dysfunction
o Arrythmia
o Unhealthy/scarred Tissue
o Uncontrolled diabetic patient
PRE-OP
CONCER
NS

17. Pre CPB- Ventricular function

18. Pre CPB - Apical VSR

19. Pre CPB – Apical VSR showing multiple jets
across thin apical septum

20. MODIFIED BICAVAL-
TR JET AND RVSP

21. PRE CPB TEE
oFair LVSF; EF - 30%, CO - 2.8L/m, CI - 1.4L/min/m2
oFair RVSF; RVEF - 26%, RVFAC - 24%, TAPSE – 11 mm
oApical VSR+,
oIt is a complex VSR at the apical ventricular septal level showing
multiple jets across the thin apical septum.
oQp/Qs=2.0
oRWMA+; Apex thinned out. Akinesia of mid mid-anterior and inferior
wall
oMild TR; Mild PAH (RVSP=46)
oMild MR

22. CPB DATA AND MYOCARDIAL PROTECTION
o Core cooling-28 degree Celsius
o 5- Blood cardioplegia
o Aortic root and RUPV vent
o CPB Time-193mins
o ACC time-127mins
o CUFF- 1100ml
o Net fluid balance- +265ml
o Core cooling- 30 degrees
celsius
o 2-blood cardioplegia
o Aortic root vent
o CPB time-99mins
o ACC time-74mins
o Net fluid balance- +265ml
CPB-I CPB-II
Roller pump, Membrane oxygenator, Crystalloid prime,
Protamine-heparin chemistry
Aortic
cannula
24Fr
Edwards
SVC 20Fr DLP
IVC 32Fr RMI
Aortic
cannula
24Fr
Edwards
RA 32/40Fr

23. o Sternum- Normal, Mild Intra-pericardial adhesion
o Moderate pericardial and Bilateral pleural effusion
o Aorta-Mildly dilated, PA mildly tense
o LV wall thinned and scarred circumferentially
around the apex with 6x5cm aneurysmal dilatation
o 2x2 cm VSR at apical part of septum with
surrounding unhealthy and scarred tissue
INTRA-
OP
FINDING
S

24. o Large Apical aneurysm
o Fragile tissue
o Moderate Biventricular dysfunction
INTRA-
OP
DIFFICULTI
ES

25. PROCEDURE
Establishment of
CPB
Standard midline
sternotomy
Aorto-Bicaval
bypass
Root cardioplegia
Arrest in diastole
1st Procedure
Distal anastomosis
of RSVG-LAD & OM
Infarct exclusion
Coming off bypass
ACC removed after deair
VOO@84/min
Inj Livosidemendan, Inj vaso,
Inj Adre
Proximal anastomosis of RSVG
Protamine reversal
Decannulation in stages
2nd
Procedure
Aorto-RA bypass
Root cardioplegia
VSR patch-pasty
Infarct exclusion
TEE- Residual
VSD with
significant
shunt

26. VSR PATCH REPAIR(DAVID’S INFARCT
EXCLUSION TECHNIQUE)+
CABG X2G ( RSVG-LAD and OM)
Procedu
re
Execute
d

27. LA
D
LV Apical
aneurysm
Infarcted
area

28. Longitudinal
ventriculoto
my

29. Infarcted
septal
tissue
Ventricular
septal defect
with multiple
openings

30. Dacron patch
placed for
infarct
exclusion

31. POST CPB 1

32. Post CPB 1

33. Post CPB 1

36. RA AND PA SPO2

37. o Going on CPB - U/E,
o CPB 1- CABG * 2G, VSR patch
o Coming off CPB1 - NSR with supports Levosimendan@0.075, Adr@0.05 & Vaso @0.0003
o Post CPB 1 TEE- initially showed a color jet within the RV in the transgastric images which were
not traced to LV in the midesophageal images. Continued imaging revealed this colour jet to be
getting prominent.
o PA sO2 - 71%, RA sO2 - 67%
o Went on CPB-2 @ protamine 75%
o For CPB 2- Inj.Heparin 5mg/kg repeated.

38. CPB DATA AND MYOCARDIAL PROTECTION
o Core cooling-28 degree Celsius
o 5- Blood cardioplegia
o Aortic root and RUPV vent
o CPB Time-193mins
o ACC time-127mins
o CUFF- 1100ml
o Net fluid balance- +265ml
o Core cooling- 30 degrees
celsius
o 2-blood cardioplegia
o Aortic root vent
o CPB time-99mins
o ACC time-74mins
o Net fluid balance- +265ml
CPB-I CPB-II
Roller pump, Membrane oxygenator, Crystalloid prime,
Protamine-heparin chemistry
Aortic
cannula
24Fr
Edwards
SVC 20Fr DLP
IVC 32Fr RMI
Aortic
cannula
24Fr
Edwards
RA 32/40Fr

39. VSD
PATCH

40. POST CPB 2

41. Post CPB 2

42. Post CPB 2

43. POST CPB TEE
oP/VSR+LV apical exclusion+CABG
oFair LVSF, EF=40%, CO=4.7 L/min, CI-2.4 L/min/m2
oContractility improved with inotropes
oMild MR/TR

44. POSTop in icu

45. X-RAY

46. POD-0
o AAI pacing
o HAI infusion
o 50ml of 5% albumin
o 30ml Cryo
o 260ml of PRBC
o Total drain- 590ml
o Total intake/output-
1483ml/2015
o PRVC MODE
o SR with a few ventricular
ectopic episodes
o SIMV+PS
o RT feed started
o Total drain- 150ml
o Pericardial drain removed
o Total intake/output-
2550/3255ml
POD-1
o SIMV
o Inj Amiodarone indusion
started
o Inj Levosimendan stopped
o Total drain- 100ml
o Right pleural drain removed
o Total intake/output-
2150/3130ml
o Inj Dytor Infusion started
POD-2
ECHO-
5mm Apical VSD L-R
shunt gradient-
63mmHg
RWMA+

47. ICU TTE – APICAL 4 CHAMBER

49. POD-2
8:00 AM
SR, Febrile
BP-86/52
10:30 AM
SVT-AF
Inj
amiodaro
ne
infusion
Reverted
to SR
11:00 AM
ECTOPICS F/B
SVT at 11:30
AM
Carotid
massage
Inj
Amiodarone
100-190/min
1:00 PM
VT/VF
DCCV-150J
VPCs/
bigeminy
Till 2:30
PM
2:30PM
VT-
236/
min, BP-
86/42
DCCV-
150J
AF /VE
6:00 PM
VT-
273/
min, BP-
48/38
DCCV-
150J
Inj.
7:30 PM
AF-FVR
continued
B/L stellate
ganglion block
gives
SR with VPC

50. POD-3
o Extubated- NIV
o Frequent VPCs- Inj
MgSo4/Xylocard
o Inj Amiodarone continue
o PCT-6.6
o Total drain- 100ml
o Left pleural drain removed
o Total intake/output-
2350/5350ml
o Inj Dytor Infusion
continued

51. POST MYOCARDIAL INFARCTION
VENTRICULAR SEPTAL DEFECT
Mechanical complications in 0.27% of STEMI cases and 0.06%
of NSTEMI cases
In-hospital mortality rates of 42.4%

52. INTRODUCTION
o Rare but lethal
complication
o Few hours to 2 weeks
post MI
o Average time 2-8 days
o M: F 3:2
o Gusto Trial- Closure to 1
day
o Shock trial -16hrs
o Chronic VSR > 4 weeks

53. EPIDEMIOLOGY
o 1-3% with reperfusion therapy
o 0.2-0.34% in fibrinolytic therapy
o O.23% in PCI ( APEX-AMI TRIAL)
o 1 vessel (50%), DVD (40%), TVD (10%)
– Gusto et al
o 3.9% in Post MI with cardiogenic
shock

54. PATHOPHYSIOLOGY (Brunn et
al.)
Ischaemia
Hyaline
degeneration
Tissue fragmentation
Enzymatic digestion
Fissure formation
Septal rupture

55. CLINICAL FEATURE
Symptoms
o Chest pain
o Shortness of breath
o Hypotension
Findings
o Harsh PSM with Thrill
o S3
o Loud P2
o Feature of cardiogenic shock
o R/S- Features of pulmonary
oedema
Sudden hypotension, the recurrence of chest pain, new cardiac murmurs suggestive of acute mitral
regurgitation or a ventricular septal defect, pulmonary congestion, or jugular vein distension should raise

57. ECG
No specific ECG features are diagnostic of post-MI VSR
May reveal AV block in 1/3rd
of patients.
Persistent ST elevation – Associated with
ventricular aneurysm

58. ECHO
• RWMA
• VSR- Location, Size,
• Basal- PLAX
• Apical- A4CV
• L-R shunt magnitude
• Ventricular function
• Doppler- 100% Sensitive
and specific in
differentiating VSR from

59. CAG
• Class I Recom.- if patient is stable before definitive
treatment of mechanical complication
• LOE- B
• Coronary intervention

60. LOCATION
o AWMI (LAD)- Apical VSR
o IWNI (RCA/LCx)- Basal
septum
o Basal septum VSR is worse
than that of AWMI apical VSR
o Simple- Through and through
defect, usually located anteriorly
o Complex- Serpiginous
dissection, remote form primary
septal defect, most commonly in
inferior VSR
ANATOMY

61. SIMPLE VS COMPLEX VSR

62. BECKERS AND MONTEGEM CLASSIFICATION
1975
Type-I
o Abrupt, slit-like
tear
o Associated with an
acute infarct <24h
Type-II
o Erosion of the
infarcted
myocardium
o Clinically correlated
with Subacute
presentation
Type-III
o Concomitant aneurysm
formation
o Significant thinning of
the septum
o Clinically correlated
with chronic
presentation

64. IMPORTANT TRIAL
o Median time from symptoms to
VSD diagnosis- 1 day
o High Risk factor- Age, Female sex
o 30-day Mortality- 74%
o 1 year mortality- 78%
CONCLUSION-
o Thrombolysis with 6 hrs reduce
risk of VSR
o VSR occur soon in thrombolytic era

65. IMPORTANT TRIAL
CONCLUSION-
o Earlier presentation of Post-MI VSR when thrombolytic therapy is
used
o VSRs occur soon in the thrombolytic era

66. IMPORTANT TRIAL
o Frequency of VSR 0.17%
o 90-day survival rate- 20% in VSR
o Factor associated with
Mechanical complication- Old
age, female, Q wave, X-ray-
pulmonary oedema,
CONCLUSION-
Rates of mechanical complication
are lower in P-PCI than those after
fibrinolytic therapy

67. MANAGEMENT
Priority of therapy- Urgent surgical closure (Class I recommendation)-
Stable patient
Hemodynamic deterioration unpredictable

68. PRE-OPERATIVE MANAGEMENT
Hemodynamic stabilisation- To minimise peripheral
organ compromise
Reduce SVR and L-R shunt
Improve and maintain coronary flow
Maintain cardiac out

70. TIMING OF SURGERY
Soon after diagnosis
Cardiogenic shock- Immediately after CAG
Hemodynamically unstable- Urgent basis
Surgery is currently regarded as the treatment
of choice
Surgical VSR repair is associated with high operative

71. DAGGET’S PATCH REPAIR
o Closes VSR by placing a patch over
the defect and suturing it to RV/LV

72. DAVID’S TECHNIQUE
o Infarct exclusion technique
o All sutures placed in the left
ventricle.

73. SURGICAL MANAGEMENT OF LV ANEURYSM
1944 Beck Fascia lata reinforcement
1955 Likoff-
Bailey
1st dosed resection
1958 Cooley 1st open resection
1973 Stoney In coat" plicature
1977 Dagget Posterior patch
1979 Levitsky Antterior patch
1980 Hutchkins Influence of cardiac geometry
1984 Jatene Circular reduction
Trend towards LV Reconstruction

74. DOR’S ENDOVENTRICULOPLASTY
o Aneurysmectomy
o Endo-ventriculoplasty with septal
exclusion
o Better geometric profile than
linear techniquw

75. VENTRICULAR
ENDOANEURYSMORRHAPHY
o Using the principle of restoration of normal shape, contour, and volume of the
ventricle.

76. POST OP MANAGEMENT
Early
complicat
ion
Bleeding
7-11%
Close monitoring
Blood Transfusion
Re-exploration (7-
11%)
Residual
VSR/shunt
23-43%
Can worsen HF
Persistent shock
Difficulty to wean
from
CPB/Ventilator
Low cardiac
output
syndrome
Due Extensive
myocardial
necrosis
Poor ventricular
function
May require IABP/
ECMO
Arrythmias
20-30% ( First 48
hrs)
VT/VF- Most
common 15-20%
Originating form
incision site
Due to reperfusion
injury and scar
tissue
AF-20%- Due to
right heart strain

77. POST OP MANAGEMENT
complicati
on
AKI
Upto-16%
Requiring dialysis
More common in
CKD
SEPSIS
Upto- 18%
Due to prolonged
ventilation/mecha
nican support
Stroke
Stroke or
neurological
events- 16 %
Respiratory
failure
Due to prolonged
ventilation

78. POST OP MANAGEMENT
o High overall 30 day mortality- influence by timing of surgery and
peri-operative status (STS-42.9%)
o LCOS/cardiogenic shock/MODS-severely impact (40-80%)
o Other key post operative predictor
o Need for RRT
o Prolonged ventilation
o Sepsis, reoperation
o Neurological events

80. THANK YOU