From the Guidelines
Atrial overload in ventricular septal rupture is primarily caused by the left-to-right shunt of blood through the septal defect, leading to increased volume and pressure in both atria. This condition occurs due to the abnormal shunting of blood from the left ventricle to the right ventricle, which increases blood volume in the right ventricle and subsequently leads to increased pressure and volume in the right atrium, as described in the management of acute myocardial infarction 1. Simultaneously, the left atrium experiences volume overload as it attempts to compensate for the inefficient cardiac output caused by the shunting. The heart tries to maintain adequate systemic circulation by increasing left ventricular filling, which places additional burden on the left atrium. This bidirectional strain results in atrial dilation and eventual dysfunction. Key factors to consider in the evaluation of ventricular septal rupture include the use of echocardiography to assess biventricular systolic function, pericardial effusion, and septal injuries, as outlined in the ACR Appropriateness Criteria for blunt chest trauma 1. The severity of atrial overload depends on the size of the septal defect, with larger defects causing more significant shunting and greater atrial stress. If left untreated, this condition can progress to atrial fibrillation, pulmonary hypertension, and eventually right-sided heart failure as the atria lose their ability to effectively manage the abnormal hemodynamic load. Some of the key points to consider in the management of ventricular septal rupture include:
- The importance of early diagnosis and treatment to prevent complications such as atrial fibrillation and pulmonary hypertension
- The use of echocardiography to evaluate the size and location of the septal defect, as well as the severity of the left-to-right shunt
- The need for surgical intervention in cases of large septal defects or significant shunting
- The potential for valvular injuries, such as mitral regurgitation, to occur in conjunction with ventricular septal rupture, as described in the evaluation of blunt cardiac trauma 1.
From the Research
Atrial Overload in Ventricular Septal Rupture
- Atrial overload in ventricular septal rupture occurs due to the left-to-right shunt caused by the rupture, leading to right ventricular volume overload, increased pulmonary blood flow, and secondary volume overload of the left atrium and ventricle 2.
- This shunt results in increased blood flow to the lungs, causing an overload of the left atrium, which can lead to atrial overload 2.
- The increased volume load on the left atrium can also lead to increased pressure, further contributing to atrial overload 2.
- The development of a postmyocardial infarction ventricular septal rupture is an uncommon but frequently fatal complication, with mortality with medical treatment only being extremely high 2.
- Surgical treatment of ventricular septal rupture consists of excluding rather than excising the infarcted septum and ventricular walls, which can help to reduce the shunt and alleviate atrial overload 2.
- Prompt diagnosis and definitive surgery are key to managing ventricular septal rupture, although mortality remains high 3, 4.
- Delaying surgery in stable patients may provide better results, but prolonged medical management is usually futile 4.
- Alternative treatments, such as percutaneous VSR closure, may be used as a temporizing measure to reduce shunt, or for patients in the sub-acute to chronic period whose comorbidities preclude surgical repair 4.