A 67‐year‐old female with end stage renal disease on hemodialysis was admitted for evaluation of hypotension. Review of systems was unremarkable except for worsening lower limb edema and exertional dyspnea. The patient was hospitalized 8 weeks prior with retrosternal chest pain. A nuclear stress test was conducted, but did not show any reversible ischemia and medical management was continued until current hospitalization.
Physical examination was significant for a blood pressure of 71/54 mm Hg and bilateral leg edema. Cardiac exam revealed a to‐and‐fro murmur. A chest radiograph showed a right‐sided pleural effusion. Echocardiogram indicated severely reduced right heart function, markedly different from the echocardiogram performed at time of prior hospitalization. A computed tomography scan of the chest done to rule out pulmonary embolism revealed a focal outpouching with contrast along the inferior interventricular septum with possible communication between the ventricular cavities, suspicious for ventricular septal defect associated with an aneurysm. A transesophageal echocardiogram and MRI confirmed the diagnosis. Subsequent coronary angiogram revealed 100% blockade of the right coronary artery which along with the above diagnosis, confirmed its post infarct nature. Given our patient’s comorbidities, a conservative percutaneous approach for repair of VSD was adopted. Because of the location and size of the pseudoaneurysm, it had to be left unrepaired. The patient had an uneventful post‐intervention hospital course.
Ventricular free wall rupture is a serious complication of MI. Anterior wall ruptures are inevitably fatal, while rupture of the inferior wall is usually contained by the pericardium forming a pseudoaneurysm. Patients with rupture of the inferior wall may be asymptomatic or present with chest pain, as in this case. A high index of suspicion is necessary for early diagnosis. When ventricular pseudoaneurysm is associated with VSD, it can lead to significant hemodynamic instability and cardiogenic shock. When feasible, a surgical approach is preferable and can be life‐saving.
Immediate post‐infarct mechanical complications of myocardial infarction (MI) are characterized by ventral septal defect (VSD), papillary muscle rupture, and ventricular free wall rupture. Co‐occurrence of VSD with ventricular free wall rupture, sealed off by the pericardium, forming a pseudoaneurysm, is an extremely rare and life threatening complication of MI. This abnormal anatomical presentation is often not suspected and can be missed on transthoracic echocardiogram.
To cite this abstract:Amlani B, Ittaman S, Martin P, Barvalia U. A Rare Case of Post‐Infarct Ventricular Septal Defect with Ventricular Pseudoaneurysm. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 317. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/a-rare-case-of-postinfarct-ventricular-septal-defect-with-ventricular-pseudoaneurysm/. Accessed March 28, 2020.