Heart, Lung and Circulation

Ventricular Double Rupture: A Rare Combination of Ventricular Septal Rupture and Concealed Post-Infarction Free Wall Rupture

Published:November 25, 2021DOI:
      A 72-year-old woman with well-controlled hypertension presented to our hospital due to worsening symptoms of heart failure. She had a history of acute anterior wall ST-elevation myocardial infarction (MI) diagnosed 2 weeks previously, when she received clinically successful fibrinolytic therapy at another regional hospital 4 hours after symptom onset. Four (4) days after hospital discharge, she gradually developed dyspnoea on exertion and orthopnoea. No recurrent chest pain was reported. On examination, her blood pressure was 120/65 mmHg with a regular pulse rate at 90/minute. There was a fine crackle at both lower lungs with a grade 3/6 parasternal pansystolic murmur. An electrocardiogram showed QS waves at V1-4. Transthoracic echocardiography revealed a left ventricular (LV) ejection fraction of 50% with akinesis of the mid-anterior segment and the whole apex. There was a high-velocity flow crossing the ventricular septum (Figure 1A, asterisk) from the LV to the right ventricle (RV), compatible with ventricular septal rupture (VSR). The estimated RV systolic pressure was 30 mmHg.
      Figure thumbnail gr1
      Figure 1An echocardiography shows a high velocity flow crossing the ventricular septum (asterisk, A) from LV to RV. Cardiac magnetic resonance confirms the 3-mm septal rupture at regional wall thinning of apical anteroseptal area (asterisks, B and C). There is a nearly complete intramyocardial tear (dash lines, D and F) covered by pericardium detected at apical inferior wall. The blood clot is evident in pericardial space adjacent to the ruptured site from the delayed enhancement (arrow, E) and long inversion time images (arrow, F).
      Abbreviations: LV, left ventricle; RV, right ventricle; PE, pericardial effusion.


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