Postinfarction Ventricular Septal Rupture Clinical Presentation

Updated: Mar 09, 2017
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Brett C Sheridan, MD, FACS  more...
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Presentation

History and Physical Examination

Upon auscultation, a loud systolic murmur is heard, usually within the first week after an acute myocardial infarction (MI). This is the most consistent physical finding of postinfarction ventricular septal rupture (VSR). Before the development of the murmur, the patient may have been stable after the acute MI. Coincident with the onset of the murmur, the patient’s clinical course undergoes a sudden deterioration, with the development of congestive heart failure (CHF) and, often, cardiogenic shock.

The typical harsh systolic murmur is audible over a large area, including the left sternal border and apical area. It sometimes radiates to the left axilla, thereby mimicking mitral regurgitation (MR). A thrill is palpable in approximately 50% of patients.

Almost 50% of patients have recurrent chest pain. The differential diagnosis includes VSR and mitral insufficiency secondary to papillary muscle rupture, papillary muscle dysfunction, or left ventricular dilatation.

Clinical features of VSR may be summarized as follows:

  • The rupture typically occurs 3-8 days after an MI
  • VSR is more likely to occur in the anterior septum than in the posterior septum (60% vs 40%)
  • The most consistent finding is a murmur
  • In the differential diagnosis, exclude MR from papillary muscle rupture
  • Diagnosis is confirmed with the aid of echocardiography and the presence of a left-to-right shunt
  • Catheterization results help determine the extent of coronary artery disease (CAD)
  • Of patients treated without surgery, 90% die
  • Surgical treatment must be carried out on an emergency basis, even if the patient is stable [3]
  • All VSRs are closed with a patch and associated coronary artery bypass grafting (CABG)
  • Operative mortality is 10-15% for anterior defects and 30-35% for posterior defects