Complications and Management of Septal Infarction

Ventricular Septal Rupture

• The European Society of Cardiology recommends that ventricular septal defect (VSD) be treated with urgent surgical intervention for survival, with an incidence of about 1-2% of all infarctions 1, 2, 3
• Severe clinical deterioration is often the first sign of VSD, accompanied by a loud systolic murmur, and diagnosis is confirmed by echocardiography 1, 2
• Color Doppler can depict the left-to-right shunt, while continuous-wave Doppler can estimate right ventricular pressure, and oxygen step-up in the right ventricle can also confirm the diagnosis 1
• Without surgical intervention, mortality is 54% within the first week and increases to 92% within the first year 1, 2
• The American Heart Association recommends initial stabilization with pharmacological treatment, including vasodilators (IV nitroglycerin) and intra-aortic balloon counterpulsation (IABP) 1, 2, 4
• Definitive treatment includes urgent surgical closure, which offers the only chance of survival in large post-infarction VSDs with cardiogenic shock 1, 2, 4
• Pre-operative coronary angiography should be performed, and bypass grafts are inserted as necessary during the procedure 1, 4
• Percutaneous closure has been reported but requires more experience before being widely recommended 1, 4
• Poor postoperative outcomes are associated with cardiogenic shock, posterior location, right ventricular dysfunction, advanced age, and long delay between septal rupture and surgery 1, 3
• Hospital mortality after surgery ranges from 25% to 60%, and 95% of survivors achieve NYHA class I or II functional status 1, 3

Heart Failure

• The European Society of Cardiology recommends management of heart failure, including oxygen therapy, diuretics (furosemide 20-40mg IV repeated at 1-4 hourly intervals), nitrates, and ACE inhibitors in the absence of hypotension, hypovolemia, or renal failure 3
• For severe heart failure, management includes inotropic agents (dopamine/dobutamine), hemodynamic assessment with balloon floating catheter, and ventilatory support if needed 3

Cardiogenic Shock

• The American Heart Association recommends management of cardiogenic shock, including oxygen therapy, hemodynamic assessment with balloon floating catheter, inotropic agents (dopamine and dobutamine), ventilatory support, and intra-aortic balloon pump 3
• Consider left ventricular assist devices and early revascularization for cardiogenic shock 3