What is the emergency and definitive management of ventricular septal rupture after myocardial infarction?

Ventricular Septal Rupture After Myocardial Infarction

Patients with ventricular septal rupture after myocardial infarction require immediate transfer to a cardiac surgical center, hemodynamic stabilization with mechanical circulatory support (preferably intra-aortic balloon pump), and urgent surgical repair—even if hemodynamically stable—because the defect can expand abruptly and cause sudden death. 1

Emergency Stabilization

Immediate Hemodynamic Support

• Insert an intra-aortic balloon pump (IABP) immediately upon diagnosis to reduce afterload, decrease shunt fraction, and provide temporary circulatory support while preparing for surgery. 1
• Start dobutamine infusion at 5–10 µg/kg/min for inotropic support to maintain cardiac output. 2
• Administer intravenous nitroglycerin if systolic blood pressure permits (>90 mmHg) to reduce afterload and shunt magnitude. 1, 3
• Target pulmonary capillary wedge pressure ≥15 mmHg and cardiac index >2 L/min/m² to optimize hemodynamics and limit shunt fraction. 2

Diagnostic Confirmation

• Obtain urgent transthoracic echocardiography with color Doppler to visualize the septal defect location, size, and quantify the left-to-right shunt. 1, 2
• Perform right heart catheterization to document oxygen step-up in the right ventricle (confirms left-to-right shunt) and measure pulmonary artery pressures. 1, 3
• Obtain coronary angiography before surgery to identify vessels requiring concomitant bypass grafting. 1

Common pitfall: Up to 50% of patients with VSR have a soft or absent murmur due to severe hemodynamic compromise, so do not exclude the diagnosis based on auscultation alone. 2

Definitive Surgical Management

Timing of Surgery

• Proceed to urgent surgical repair within 24 hours regardless of hemodynamic stability, because even stable patients can deteriorate abruptly as the defect enlarges. 1, 2
• The 2025 ACC/AHA guidelines emphasize that patients should be managed at facilities with cardiac surgical expertise and that mechanical circulatory support devices are reasonable as a bridge to surgery. 1
• Do not delay surgery beyond initial stabilization—the defect can expand unpredictably, and prolonged delay increases risk of sudden collapse and death. 1, 3

Surgical Approach

• Perform ventricular septal defect closure with pericardial patch repair via left ventriculotomy, often using an infarct exclusion technique. 4
• Add coronary artery bypass grafting to all diseased vessels identified on angiography during the same operation. 1
• Surgical mortality ranges from 20–87% depending on patient condition, with cardiogenic shock, posterior location, right ventricular dysfunction, and advanced age predicting worse outcomes. 1, 3

Critical caveat: Inferior-basal (posterior) VSRs carry significantly higher mortality than anterior-apical defects due to technical complexity and associated right ventricular dysfunction. 1

Prognosis Without Surgery

• Without surgical intervention, 54% of patients die within the first week and 92% within one year. 1, 3
• Medical therapy alone results in near-universal mortality, making surgery mandatory even in high-risk patients. 2
• Among surgical survivors, 5-year survival is approximately 60–70%, with 95% achieving NYHA class I or II functional status. 1, 3

Alternative Approaches

Percutaneous Closure

• Percutaneous device closure remains investigational and should only be considered for patients with prohibitive surgical risk or as a temporizing measure. 1
• Residual shunts are common after percutaneous closure, and long-term durability data are lacking. 1, 5
• The 2003 ESC guidelines state that more experience is needed before percutaneous closure can be recommended as standard therapy. 1

Advanced Mechanical Support

• In patients requiring additional stabilization beyond IABP, consider VA-ECMO or other mechanical circulatory support devices as a bridge to surgery, though the 2025 ACC/AHA guidelines note that routine use is not supported by randomized trial data. 1
• Case reports suggest that Impella support may allow delayed surgery (beyond 7 days) to permit infarct maturation and reduce surgical risk, but this remains an evolving strategy without guideline endorsement. 6

Key Clinical Pearls

• VSR typically occurs within the first 24 hours in the reperfusion era, though delayed presentations up to 7 days post-MI still occur. 1, 2, 7
• The classic presentation includes sudden hemodynamic deterioration, new harsh holosystolic murmur radiating to the right sternal border, and pulmonary congestion—but remember that the murmur may be absent. 2
• Recurrent chest pain with ST-segment re-elevation may mimic reinfarction but should prompt immediate evaluation for mechanical complications. 1, 2
• Transfer to a tertiary center with cardiac surgery and shock team expertise should occur immediately upon diagnosis, as the 2025 ACC/AHA guidelines emphasize multidisciplinary management. 1