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Post-MI Ventricular Septal Rupture — EECC MCQ

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HardCoronary Artery DiseasePost-MI Ventricular Septal RuptureEECC

A 70-year-old man presents 5 days after an anterior MI with new chest pain, a loud pansystolic murmur, and a palpable thrill at the left sternal edge. He develops acute pulmonary oedema and cardiogenic shock. Echocardiography shows a ventricular septal defect (VSD) with left-to-right shunting. What is the definitive management?

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Correct answer: B — Emergency surgical VSD repair, with mechanical circulatory support as a bridge if haemodynamically unstable

Post-MI ventricular septal rupture (VSR) is a mechanical complication typically occurring 3-5 days after MI, presenting with a new harsh pansystolic murmur with thrill, acute haemodynamic deterioration, and echocardiographic evidence of VSD with left-to-right shunt (step-up in oxygen saturation in the RV on catheterisation). It carries very high mortality without surgical repair. The ESC ACS Guidelines recommend emergency surgical repair (Class I), with IABP or percutaneous MCS (Impella, VA-ECMO) as a bridge in patients with cardiogenic shock. Percutaneous device closure is technically challenging in the acute setting due to friable necrotic tissue and is generally reserved for select cases or as a bridge to surgery.

Reference: ESC (2023): Guidelines for the Management of Acute Coronary Syndromes