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Post-MI Ventricular Septal Rupture — EECC MCQ

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ModerateCoronary Artery DiseasePost-MI Ventricular Septal RuptureEECC

A 55-year-old man with STEMI undergoes successful primary PCI. Three days later he develops a new harsh pansystolic murmur loudest at the left sternal edge with a thrill. His haemodynamics rapidly deteriorate. What mechanical complication should be suspected?

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Correct answer: E — Ventricular septal rupture (VSR) — presenting with a new pansystolic murmur, haemodynamic deterioration, and step-up in oxygen saturation from RA to RV on right heart catheterisation; requires urgent surgical repair or percutaneous closure

Post-MI mechanical complications occur in 1-5% of STEMIs (less common in the reperfusion era): (1) VSR: new harsh pansystolic murmur + thrill at LSE, typically days 3-7 post-MI; diagnosis: echo (defect in interventricular septum with left-to-right shunt on colour Doppler), RHC (O₂ step-up from RA to RV); (2) papillary muscle rupture: acute severe MR with pansystolic murmur at apex, massive pulmonary oedema; (3) free wall rupture: tamponade, electromechanical dissociation, usually fatal. VSR management per ESC 2023 ACS Guidelines: (1) haemodynamic support (IABP, inotropes); (2) urgent surgical repair (patch closure) — delay may be preferred if patient can be stabilised (early repair in friable necrotic tissue has high failure rates, but delayed repair risks multi-organ failure); (3) percutaneous closure devices in selected cases (particularly muscular VSR).

Reference: ESC (2023): ACS Guidelines