Ventricular septal rupture (VSR) is a devastating complication following myocardial infarction. It occurs in 0.17-0.31% of cases post-primary PCI, usually 2-8 days post-MI. Risk factors include older age, female sex, late presentation, extensive MI, hypertension, and lytic therapy. Diagnosis involves acute deterioration, auscultation findings, echocardiogram, and CT scan. Management uses a hybrid approach of primary PCI of the culprit vessel followed by transient mechanical support like IABP, then definitive surgical or percutaneous repair. Without treatment, mortality is over 90% at 1 year. Challenges include friable tissue that cannot hold sutures early on and

1. Ventricular septal rupture
Ahmed ElBorae, MSc
Assistant lecturer of Cardiology, Cairo University

2. Introduction
• (VSR) remains a devastating complication following MI
• Incidence: Decreased from 1-3% “pre-reperfusion era” to “0.17-0.31%” post
1ry PCI, [RCA in 46%- LAD in 42%]
• Onset: Average 2-8 days post MI, yet might occur earlier
• Risk factors: Old age-female-Late presentation-extensive MI HTN-Lytic therapy
• Diagnosis: Acute deterioration-auscultation “V.important”- Echo- MSCT
• Management: Hybrid approach (1ry PTCA of culprit- transient mechanical
support e.g. IABP) then definitive (Surgical or percutaneous)
• Prognosis: Without treatment > 90% mortality at 1 year
Venu M, et al. Contemporary Management of Post-MI Ventricular Septal Rupture. JACC 2018

3. Hemodynamics
• Acute left to right shunt (Volume
overload of infarcted ventricle)
• Decrease cardiac output
• Acute rise of pulmonary flow
• Acute rise in PCWP
• High LV afterload due to
peripheral vasoconstriction
• So, we need do decrease LV
afterload
VSR

4. IABP
Other : ECMO- Tandem heart- Impella

5. Challenges
• Friable tissue couldn’t hold sutures (need weeks for collagen
maturation)
• Basal septal VSR (following Inferior MI) more serpiginous, larger, with
more intra-myocardial dissection, possible extension to free wall
• For anterior defects, operative mortality ranges from 10% to 15%; and
30% to 35% for posterior defects

6. Early ? Late ?
Proper timing of intervention

7. Proper timing
Venu M, et al. Contemporary Management of Post-MI Ventricular Septal Rupture. JACC 2018

8. How to interpret these numbers?
• Patients with more hemodynamic compromise > more urgent
intervention> higher operative mortality
• Patients with more stable hemodynamic > delayed intervention>
more stable tissue and dynamics> lower operative mortality
• No data about the mortality rate in patients awaiting delayed surgery
strategy
Natural selection

9. M. Shahreyar, et al., Post-myocPost-MI VSR.Cardiovascular Revascularization Medicine
Practical approach

10. Surgical repair
• Traditional repair:
Infarctectomy+ patch sutured to
edges of the defect if large
defect, direct suture if small
• David repair
Concept: Infarction exclusion
strategy to minimize stress on the
infarcted wall using pericardial
patch
• Two or three patch repair:
Septal + free wall patches

11. Percutaneous device closure
• Planning: Defect size,
site , margins, shape
“defects <15 mm are
ideal”
• Crossing Lt to Rt>
arterio-venous rail >
closure from RV side
• Procedure success rate
as high as 89% but 30-
day mortality of 32%,
dislocation 13%

12. Timing?
Early closure before 14 days
M. Shahreyar, et al., Post-myocPost-MI VSR.Cardiovascular Revascularization Medicine

13. Thank You
Latham 1845, UK
First to describe VSR at autopsy
Denton Cooley 1956, USA
First VSR repair