What are the diagnostic steps and management for suspected ventricular septal rupture?

From the Guidelines

Suspected ventricular septal rupture (VSR) requires prompt diagnosis and management, with the most recent guidelines from 2025 emphasizing the importance of timely reperfusion therapy and definitive surgical correction 1.

Diagnostic Steps

The initial evaluation should include a thorough physical examination looking for a new harsh holosystolic murmur, often with a palpable thrill, and signs of heart failure or cardiogenic shock.

• Diagnostic confirmation involves transthoracic echocardiography, which can visualize the defect and assess its size, location, and hemodynamic impact, as recommended by the 2020 ACR Appropriateness Criteria for blunt chest trauma-suspected cardiac injury 1.
• If echocardiography is inconclusive, transesophageal echocardiography offers better visualization.
• Right heart catheterization can detect an oxygen step-up between the right atrium and ventricle, while left ventriculography can demonstrate contrast shunting across the defect.

Management

Management begins with medical stabilization using vasodilators like nitroprusside to reduce afterload, inotropes such as dobutamine to support cardiac output, and diuretics to manage pulmonary congestion.

• Mechanical circulatory support with an intra-aortic balloon pump or extracorporeal membrane oxygenation may be necessary for hemodynamic stabilization, as noted in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes 1.
• Definitive treatment is surgical repair, with the 2025 guidelines suggesting that early corrective surgery is the treatment of choice for mechanical complications of MI, although the exact timing remains uncertain 1.
• The surgical approach involves patch closure of the defect, with concurrent coronary artery bypass grafting if needed.
• Percutaneous closure may be considered in selected high-risk patients, as mentioned in the 2003 European Society of Cardiology guidelines for the management of acute myocardial infarction 1.
• Close monitoring in an intensive care setting with serial echocardiography is essential throughout management, with the goal of reducing morbidity, mortality, and improving quality of life.

From the Research

Diagnostic Steps for Ventricular Septal Rupture

• Clinical presentation: Ventricular septal rupture (VSR) is a rare but life-threatening complication of acute myocardial infarction, associated with high mortality despite prompt treatment 2, 3, 4.
• Diagnosis: The diagnosis of VSR is typically made using a combination of clinical, echocardiographic, and hemodynamic criteria 4, 5.
• Echocardiography: Transthoracic and transesophageal echocardiography are essential tools for diagnosing VSR, allowing for the visualization of the defect and assessment of its size and location 3, 4.

Management of Ventricular Septal Rupture

• Surgical treatment: Surgery represents the standard of care for VSR, with the goal of closing the defect and restoring normal cardiac function 2, 4, 5.
• Timing of surgery: The optimal timing of surgery is still a matter of debate, with some studies suggesting that delayed surgery may be associated with better survival rates 6, 5.
• Mechanical circulatory support: Mechanical circulatory support, such as extracorporeal membrane oxygenation (ECMO), may be used to stabilize patients with VSR and allow for delayed surgery 6.
• Percutaneous closure: Percutaneous closure of the defect may be considered as an alternative to surgery in selected patients, although the results are not superior to surgery 3, 4.

Factors Associated with Mortality

• Cardiogenic shock: Cardiogenic shock is a significant predictor of mortality in patients with VSR, with a higher mortality rate observed in patients who undergo emergent or salvage surgery 5.
• Age: Older age is an independent predictor of mortality in patients with VSR, with a higher risk of death observed in older patients 5.
• Preoperative cardiac arrest: Preoperative cardiac arrest is also an independent predictor of mortality in patients with VSR, with a higher risk of death observed in patients who experience cardiac arrest before surgery 5.