Cardiac Rupture: A Case Report

Abstract

Introduction: Post-infarction ventricular septal defect (VSD) is a serious and potentially fatal complication of acute myocardial infarction (AMI), with an incidence of 1–2%. Although it typically presents with symptoms such as chest pain, cardiogenic shock, or pansystolic murmur, it can manifest atypically, especially in older adults. This article describes a unique case of post-infarction VSD in a 62-year-old patient with nonspecific systemic symptoms that delayed diagnosis and treatment.
Objective: To highlight the importance of the clinical suspicion index in patients with cardiovascular risk factors and atypical presentations to improve early diagnosis and management of serious mechanical complications such as post-infarction VSD.
Case Report: A 62-year-old man, a smoker with recent hypertension (on enalapril) was brought to the emergency department with general malaise, asthenia, and hypotension without chest pain. The patient reported profuse diarrhea for a week, accompanied by muscle pain in the back and neck. Upon arrival, he presented with complete atrioventricular block, acute renal failure with severe metabolic acidosis, hyperkalemia, liver dysfunction, and coagulopathy. Troponin I (88,269 pg/mL) and massive transaminases (GOT: 4,760 U/L, GPT: 4,006 U/L) levels confirmed AMI. An echocardiogram revealed a post-infarction VSD with an initial Qp/Qs of 4.6. Coronary angiography showed complete occlusion of the middle right coronary artery. The patient underwent surgery on 06/24/2024 by exclusion of the VSD with a pericardial patch. However, he developed complications such as atrial fibrillation, cardiac tamponade, and apical patch dehiscence, requiring percutaneous closure with Amplatzer devices, achieving a residual Qp/Qs ratio of approximately 2. During his course, he required intra-aortic balloon pump (IABP), venoarterial extracorporeal membrane oxygenation (VA-ECMO), and intensive multidisciplinary management. He was ultimately discharged with residual heart failure and was followed up as an outpatient.
Comments: This case underscores how the atypical presentation of a complicated AMI can delay diagnosis and worsen the prognosis. The absence of chest pain and the predominance of systemic symptoms highlight the need to maintain a high index of suspicion in patients with cardiovascular risk factors. Post-infarction VSD requires a multidisciplinary approach that includes early surgery, aggressive hemodynamic management, and close monitoring. Furthermore, the frequent complications associated with surgical repair, such as patch dehiscence and cardiac tamponade, highlight the importance of advanced techniques such as percutaneous closure to optimize outcomes. Future research should focus on identifying specific biomarkers and developing early detection protocols to improve survival in this critical population.