Ventricular Septal Rupture

Etiology

The most common cause of ventricular septal rupture is full-thickness (transmural) MI in 1 of the following coronary arteries:

• Left anterior descending coronary artery: This artery supplies most of the anterior portion of the interventricular septum; it can lead to apical VSR.
• Dominant right coronary artery: This artery supplies the most inferior portion of the interventricular septum—this can lead to a basal VSR.
• The dominant left circumflex artery: This artery supplies the posterior portion of the posterior descending artery and arises from the circumflex branch.

Partial-thickness infarcts such as non-ST elevation MI or unstable angina can also increase the risk of ventricular septal rupture.

Epidemiology

Before the availability of thrombolytic and percutaneous intervention, the incidence of ventricular septal rupture was approximately 2%.[2] With the advent of effective therapy and reduced time to revascularization, the incidence of ventricular rupture has been reduced to 0.31%.[3] According to the Global Registry for Acute Coronary Events (GRACE) study, the rate of ventricular septal rupture in an acute MI treated with percutaneous intervention is less (0.7%) than the myocardial infarction in patients treated with thrombolytic therapy (1.1%).[4] The incidence also depends upon the type of MI and is higher in patients with ST-segment elevation MIs (0.9%). The occurrence of non-ST-segment elevation MI and unstable angina is 0.17% and 0.25%, respectively. There is no difference in the ventricular septal rupture rate based on the infarction's location, whether anterior or inferolateral.[3]

Pathophysiology

The blood flow to the septum is derived from branches of the left anterior descending coronary artery and the posterior descending coronary artery. The blood supply may also be from the circumflex artery in rare cases. The infarct is usually transmural and extensive. Nearly two-thirds of VSR occur in the anterior septal wall, and about one-third occur in the inferior or posterior wall. When the latter is involved, it is often accompanied by mitral valve insufficiency secondary to papillary muscle dysfunction/rupture. At autopsy, the culprit coronary artery is almost completely occluded with the absence of collaterals. In rare cases, there may be multiple septal perforations.

The most common pathological finding of an infarcted septum is coagulation necrosis, defined as dry denaturation of proteins due to a lack of oxygen due to a loss in blood supply. This progresses to the thinning and weakening of the septum, which usually takes 3 to 5 days after acute MI. Ventricular septal rupture can also occur within 24 hours of myocardial infarction due to the dissection of an intramural hematoma or hemorrhage into the diseased myocardium. The primary mechanism behind ventricular septum rupture is physical shear stressors, especially at the junction of the infarct area and normal healthy myocardium. Due to this mechanism, ventricular aneurysm, free wall rupture, or papillary muscle rupture are associated with ventricular septum rupture. Cardiac free wall rupture and ventricular septum rupture after MI are similar regarding pathological characteristics. There is a pathological classification regarding free wall rupture, which we can use for ventricular septum rupture, as proposed by Becker.[5] There are 3 types, which are as follows:

1. Type I: Sudden in onset, slit-like tear, within 24 hours
2. Type II: Subacute, erosion of infarcted myocardium
3. Type III: Late presentation, aneurysm formation, and rupture; associated with older infarcts

After establishing the new connection between the right and left ventricle due to ventricular septum rupture, oxygenated blood shunts from the high-pressure left ventricle to the low-pressure right ventricle. The natural course of VSR after an MI is short. The condition is progressive, and more than 90% die within the first 12 months. The poor prognosis is chiefly due to the sudden volume overload on both ventricles, which a large MI already compromises. Additionally, the patient may have superimposed ventricular pseudoaneurysm or mitral valve insufficiency, compromising ventricular function. Only a few reports of patient survival following medical therapy exist.

History and Physical

The patient may present with flash pulmonary edema after 1 to 3 days following a stable MI; severe cases present with cardiogenic shock.[6] Auscultation will reveal a loud systolic murmur following an MI. This feature is universally heard in most cases of VSR. The murmur is usually heard over the entire precordium. Some patients may also feel a thrill. Due to increased right heart flow, sometimes there is a loud pulmonic component of the second heart sound, tricuspid regurgitation, or third heart sound.

Almost all patients complain of recurrent chest discomfort. The patient may have a sudden hemodynamic change at the onset of the murmur. The risk factors for ventricular septal rupture include female sex, increased age, first episode of myocardial infarction, ST-segment elevation myocardial infarction, high GRACE risk score, and chronic kidney disease.[6] A patient having an acute MI may present with hypotension or is hemodynamically unstable; this should prompt evaluation for ventricular septal rupture.

Evaluation

The chest x-ray may reveal left ventricular enlargement and florid pulmonary edema. Two-dimensional echocardiography with Doppler is used to diagnose ventricular septal rupture, which shows blood flow across the ventricular septum.[7] An echocardiogram also demonstrates right ventricular dilatation and pulmonary hypertension due to increased right-sided blood flow. The color Doppler echocardiography is also useful in evaluating the anatomical size of a rupture. 

Transoesophageal echocardiography is indicated in patients in whom it is difficult to get an adequate view of the myocardium via transthoracic echocardiograms. These may include patients on a mechanical ventilator or with a large body habitus. An electrocardiogram is needed to rule out reinfarction, and it may show elevated ST segments in patients with a ventricular aneurysm. A heart block may be present in 30% of the patients. Cardiac catheterization is only undertaken in patients who are stable and require good judgment. The procedure can help differentiate VSR from mitral regurgitation. In VSR, the patient will have a step-up of oxygen between the right atrium and the pulmonary artery.

Treatment / Management

Ventricular septal rupture requires an interprofessional team, including an interventional cardiologist and cardiothoracic surgeon. The ultimate treatment is surgical repair.[8] Before surgical repair, restoring the circulation in the diseased artery is necessary to decrease the hypoxic burden in the infarcted area, especially in cases of right ventricular involvement. (A1)

To stabilize the patient, the afterload must be reduced with vasodilators. These agents may also decrease the left-to-right shunt associated with the VSR. Intravenous nitroglycerin is often used to improve myocardial blood flow and vasodilate the vessels. Inotropic support may be required in patients with low cardiac output. However, vasopressors can increase afterload and worsen the left-to-right shunt. The intra-aortic balloon pump is vital for temporary hemodynamic support in these patients. The device lowers afterload and also decreases the shunt; at the same time, it facilitates coronary perfusion. As soon as the patient is stable, surgery should be performed. Surgery should only be delayed in the following cases:

• No evidence of cardiogenic shock
• Patient has good perfusion and cardiac output
• Minimal or no signs of congestive heart failure
• Minimal use of vasopressors
• No retention of fluid
• Normal kidney function

Surgical Closure

There are 2 surgical techniques for repairing ventricular septal rupture, including the Daggett and David procedures. 

• Daggett procedure: Patch over the defect with sutures in both ventricles (infarct inclusion technique)
• David procedure: Patch over the rupture with stitches in the left ventricle only (infarct exclusion technique)

Due to the proximity of papillary muscles, repairing a posterior ventricular septal rupture is more challenging than an anterior rupture. If the ventricular septal rupture develops within 24 hours of an MI, surgical intervention is difficult, as it is challenging to differentiate between healthy and newly infarcted tissue. Also, at this point, the muscle is weak and unable to hold the sutures. Additional procedures that may be required during the report of a VSR include mitral valve replacement, coronary artery bypass, and resection of the left ventricular aneurysm.

Percutaneous Closure

With advances in techniques, the percutaneous closure of a VSR has also been developed. In some patients, a balloon catheter has been used to occlude the shunt. However, this is only a temporary fix. Anticoagulation is recommended after surgery because a large amount of prosthetic material is used to close the VSR. Unfortunately, residual VSR develops in 10% to 25% of cases, even in the best hands. The patient may be observed if the VSD is small and the shunt is not large. Otherwise, repeat surgery is recommended. Some patients have benefited from percutaneous closure after the initial surgical approach. However, complications like embolization, ventricular perforation, and ventricular arrhythmias have been reported.

The mortality of surgical intervention within 24 hours of acute MI is over 60%. In contrast, the untreated ventricular septal rupture has a 40% to 80% mortality. Late surgical intervention has a good prognosis; however, this may not be an option for a patient with hemodynamic compromise. Surgical intervention within 7 days of this complication has a mortality of 54.1%. On the other hand, surgery after 7 days has a death rate of 18.4%.[9] Patients presenting with cardiogenic shock need an intra-aortic balloon counterpulsation to reduce afterload and increase cardiac output. Percutaneous intervention can repair anterior defects and ventricular septal defects less than 1.5 cm in diameter, but this technique is still in an evolutionary phase.[10]

Differential Diagnosis

The differential diagnosis includes the following:

• Acute mitral regurgitation due to papillary muscle rupture
• Free wall rupture
• Tricuspid regurgitation
• Congenital ventricular septal defect
• Atrial septal defect
• Acute flash pulmonary edema

Prognosis

Post-MI VSR is a lethal disorder and carries a high mortality. The earlier the repair, the higher the mortality, as the sutures do not hold in friable tissue. A longer delay allows for fibrosis to set in, and thus, suturing is easier. The mortality is also high in patients with cardiogenic shock. Overall mortality is slightly lower for patients with an anterior VSR compared to a posterior VSR. Other negative prognostic factors include advanced age, multiorgan failure, and advanced New York Heart Association class. Predictors of mortality within 30 days include:

• Shock at surgery
• Renal failure
• Need for emergency intervention
• Significant coronary disease, especially right coronary and circumflex disease
• Duration of surgery
• Prolonged cardiopulmonary bypass time
• Incomplete revascularization

The prognosis is favorable if the rupture size is small and the patient is hemodynamically stable during surgical repair. 

Complications

Possible complications include the following:

• Cardiogenic shock
• Ventricular aneurysm
• Thrombus formation
• Ventricular arrhythmias
• Free wall rupture
• Death [11]