Septal rupture with right ventricular wall dissection after myocardial infarction
© Soriano et al; licensee BioMed Central Ltd. 2005
Received: 25 September 2005
Accepted: 20 October 2005
Published: 20 October 2005
In patients with inferior myocardial infarction, septal rupture generally involves basal inferoposterior septum, and the communicating tract between left and right ventricle is often serpiginous with a variable degree of right ventricular wall extension. Right ventricular wall dissection following septal rupture related with previous myocardial infarction has been reported in a very few cases, in many of them this condition has been diagnosed in post-mortem studies. In a recent report long-term survival has been achieved after promptly echocardiographic diagnosis and surgical repair.
We present a case of a 59-year-old man who had a septal rupture with right ventricular wall dissection after inferior and right ventricular myocardial infarction. Transthoracic echocardiography, as first line examination, established the diagnosis, and prompt surgical repair allowed long-term survival in our patient.
Outcomes after right ventricular intramyocardial dissection following septal rupture related to myocardial infarction has been reported to be dismal. Early recognition of this complication using transthoracic echocardiography at patient bedside, and prompt surgical repair are the main factors to achieve long-term survival in these patients.
KeywordsSeptal rupture myocardial infarction transthoracic echocardiography transesophageal echocardiography
The occurrence of ventricular septal rupture after acute myocardial infarction is an uncommon complication in the reperfusion era , however, this condition implies a high mortality rate, even after surgical repair . In patients with inferior myocardial infarction, septal rupture generally involves basal inferoposterior septum, and the communicating tract between left and right ventricle is often serpiginous with a variable degree of right ventricular wall extension . Right ventricular wall dissection following septal rupture related to previous myocardial infarction has been reported in a very few cases [4–6], in many of them this condition has been diagnosed in post-mortem studies . In a recent report long-term survival has been achieved after promptly echocardiographic diagnosis and surgical repair .
Outcomes after right ventricular intramyocardial dissection following septal rupture related to myocardial infarction has been reported to be dismal. As far as we know only two cases of this condition have been reported achieving long-term survival after surgical repair. According to Tighe et al , and taking into account that only two hours passed since symptoms' beginning to surgery, prompt echocardiographic diagnosis and surgical repair were probably the main factors that contributed to the long-term survival in our case. No additional surgical manoeuvre was performed on right ventricular dissected wall, however during postoperative evolution right ventricular intramyocardial neo-cavity resolved, as demonstrated by means of transesophageal echocardiography performed one month after surgical intervention (figure 1, panel C). Spontaneous apposition of right ventricular dissected layers and thrombosis of intramyocardial neo-cavity were simply facilitated after septal rupture closure.
When clinical suspicion of ventricular septal rupture complicating acute myocardial infarction is present, transthoracic and/or transesophageal echocardiography at patient bedside is the test of choice for early diagnosis and therapy guidance. Taking into account that complex forms of ventricular septal rupture with right ventricle involvement are critical prognostic factors , carefully echocardiographic recognition of complex dissecting tracts through the septum and right ventricular wall is of paramount importance. For this purpose, the use of unconventional echocardiographic views with color flow Doppler mapping, specially the use of subcostal views for visualize right ventricular free wall, allow to detect the left ventricular entry site and the right ventricular exit site of the septal rupture.
- Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, Vahanian A, Califf RM, Topol EJ: Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000, 101: 27-32.View ArticlePubMedGoogle Scholar
- Pretre R, Ye Q, Grunenfelder J, Lachat M, Vogt PR, Turina MI: Operative results of "repair" of ventricular septal rupture after acute myocardial infarction. Am J Cardiol 1999, 84: 785-788. 10.1016/S0002-9149(99)00438-5View ArticlePubMedGoogle Scholar
- Birnbaum Y, Fishbein MC, Blanche C, Siegel RJ: Ventricular septal rupture after acute myocardial infartion. N Engl J Med 2002, 347: 1426-1432. 10.1056/NEJMra020228View ArticlePubMedGoogle Scholar
- Scanu P, Grollier G, Lamy E, Commeau P, Valette B, Lognone T, Granger D, Galateau F, Potier JC: Myocardial dissection in infarction of the right ventricle. Clinical, echocardiographic and pathological aspects. Arch Mal Coeur 1992, 85: 423-428.PubMedGoogle Scholar
- Galrinho A, Loureiro J, Magalhaes MP: Intramyocardial dissection with rupture of the right ventricle after an acute myocardial infarction-A rare complication diagnosed by transesophageal echocardiography. Eur J Echocardiography 2003, 4: 152-153. 10.1053/euje.2002.0633View ArticleGoogle Scholar
- Tighe DA, Paul JJ, Maniet AR, Flack JE 3rd, Mannion JD, Rifkin RD, Raichlen JS: Survival in infarct related intramyocardial dissection. Importance of early echocardiography and prompt surgery. Echocardiography 1997, 14: 403-408.View ArticlePubMedGoogle Scholar
- Vargas-Barron J, Molina-Carrion M, Romero-Cardenas A, Roldan FJ, Medrano GA, Avila-Casado C, Martinez-Rios MA, Lupi-Herrera E, Zabalgoitia M: Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction. Am J Cardiol 95: 1153-8. 2005 May 15 10.1016/j.amjcard.2005.01.041
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.