Echocardiographic Observations on Ventricular Septal Rupture Complicating Acute Myocardial Infarction By P. A. N. CHANDRARATNA, M.D., M.R.C.P., P. K. BALACHANDRAN, M.D., P. M. SHAH, M.D., AND M. HODGES, M.D. SUMMARY

Echocardiograms were performed on three patients with ventricular septal rupture complicating myocardial infarction. The pulmonary artery mean pressure was 30 mm Hg or more in all three patients. The size of the ventricular septal defect, determined at operation or autopsy, was 2 cm or greater in each patient. The salient echocardiographic abnormality was dilatation of the right ventricle. The direction of septal motion was normal in all the patients. The left atrial diameter was slightly increased in one patient and was normal in the other two. In one patient, an unusual pattern of mitral valve motion was seen. Complete closure of the mitral valve after its initial opening in early diastole was observed and this was followed by almost complete reopening of the valve. This pattern was suggestive of increased blood flow through the mitral valve. Although some of these findings are nonspecific, the combination of echocardiographic findings may provide useful clues to the diagnosis of septal perforation.

Additional Indexing Words: Ultrasound

Myocardial infarction

tion of echocardiographic findings may provide useful clues to the diagnosis of ventricular septal rupture. Materials and Methods

ECHOCARDIOGRAPHY was introduced by Edler and Hertz' as a useful means of studying mitral valve function. This technique has subsequently been widely used to investigate various intracardiac structures. Right and left ventricular dimensions, left atrial size and aortic root diameter can all be accurately measured using ultrasound.2 3 The range of normal values for these various structures has been established; and the abnormalities that occur in different forms of heart disease have been described.4

Ventricular septal defect

Three patients with acute myocardial infarction and ruptured ventricular septum were studied. Two of these patients were admitted to the University of Rochester Medical Center and the third was seen at the Mount Sinai Medical Center. None of them had a past history of a heart murmur or congestive cardiac failure. Cardiac catheterization was performed shortly after admission in all three patients. Informed consent was obtained from each patient prior to cardiac catheterization. Echocardiography was performed using a commercially available ultrasonoscope and a 0.5 inch, 2.25 MHz transducer. With each patient in the supine position, the transducer was placed in the third or fourth interspace at the left sternal edge and the mitral valve, aortic root, left atrium, and left ventricle echograms were recorded.

8

Ventricular septal rupture is a rare and ominous complication of acute myocardial infarction. Since surgical correction of the defect is sometimes feasible, accurate diagnosis of septal rupture is important. The hemodynamic and echocardiographic findings in three patients with ventricular septal defect secondary to myocardial infarction are presented. Although many of these features are nonspecific, the combina-

Results

The clinical data on our patients are presented in table 1. The first patient (WF) sustained an inferior infarct, the second (DW) had an infero-lateral infarct, and the third (SK) had an antero-septal myocardial infarct. Ventricular septal rupture occurred on the fifth, second and third day, respectively. The patients presented with chest pain, hypotension or congestive cardiac failure. A loud systolic murmur and systolic thrill were noted at the lower left sternal border in two patients (WF, SK). The third patient (DW) had a somewhat atypical grade 111/VI mid-systolic murmur

From the Department of Medicine, Division of Cardiology, Mount Sinai Medical Center, Miami Beach, the University of Miami School of Medicine, Coral Gables, Florida, and the University of Rochester Medical Center, Rochester, New York. Address for reprints: P. A. N. Chandraratna, M.D., Division of Cardiology, Mt. Sinai Medical Center, 4300 Alton Road, Miami Beach, Florida 33140. Received August 30, 1974; revision accepted for publication October 11, 1974. 506

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ULTRASOUND IN VENTRICULAR SEPTAL RUPTURE Table 1

Clinical Data

WF

Age

Sex

ECG

59

M

Inferior

Day of rupture

5

DW

62

Inferolateral

M

2

Chest pain, CCF, low output state

3

CCF

infarct SK

70

Anteroseptal infarct

F

Systolic thrill and grade V/VI holosystolic murmur at the lower left sternal border Grade III/VI harsh midsystolic murmur at the left sternal border and

Chest pain,

hypotension

infarct

Outcome

Physical signs

Presentation

apex Thrill and grade IV/VI holosystolic murmur at the lower left sternal border

Emergency surgery. Operative death Surgery five weeks after septal rupture. Successful repair of VSD Died after nine days

Abbreviations: CCF - congestive cardiac failure; VSD = ventricular septal defect.

enlarged right ventricle. Coronary arteriography in patient WF revealed significant occlusions in the right coronary artery, first marginal artery and circumflex artery. Patient DW had total occlusion of the distal circumflex and left anterior descending coronary arteries. The operative or autopsy data are outlined in table 3. Patient WF had an infarct involving the inferior wall and the posterior half of the interventricular septum. There was a 2 cm ventricular septal defect (VSD) in the inferior part of the muscular septum. A total occlusion of the left main coronary artery was found at autopsy in patient SK. She had a 2.5 cm VSD and massive infarction of the septum. The echocardiographic findings in our patients are

which was of equal intensity at the left sternal edge and the apex. The first patient had emergency surgery and died at operation. Successful repair of the ventricular septal defect was achieved in the second patient five weeks after septal perforation. The third patient died of intractable cardiac failure and cardiogenic shock after nine days. The hemodynamic data of the three patients are shown in table 2. All three patients had a pulmonary artery mean pressure of 30 mm Hg or more. Patients DW and SK were noted to have left-to-right shunts at the ventricular level of 3.2:1, and 2.4:1, respectively. The left ventricular angiogram in the first and second patients showed a large ventricular septal defect in the lower part of the muscular septum and a markedly

Table 2 Hemodynamic Data RV

PA

Patient

RA (mm Hg)

(mm Hg)

(mm Hg)

WF

11

43/13

43/20

PAW

LV

SA

(mm

Hg)

93/17

108,'64 79

LV angio

Coronary angio

Large VSD in the

Total occlusion of RCA in its distal third. 90% stenosis of origin of first marginal. 90% stenosis of the CCA 2 cm distal to the first marginal. LAD had nonocclu-sive disease. Total occlusion of the distal circumflex artery. Total occlusion of the terminal LAD. Small non dominant, normal RCA.

QP/QS

inferior portion of septum, mild mitral incompetence, slight reduction of LV

30

contractility, DW

58/24 34

20

120/78 82

3.2:1

SK

60/24

19

108/75 90

2.4:1

dilated RV Large VSD in the lower portion of the muscular septum, dilated RV

35

Abbreviations: RCA

=

right coronary artery; CCA

=

circumflex coronary

artery:

LCA

=

left coronarv artery.

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5CHANDRARATNA ET AL.

5()8

Table 3 Operative or Autopsy Data WXF

l)W

SK

Marked (dlatat :itioni of lhe heatl inifarct ioni of the 1)o)Steol()-ilfer'ioI sur'fael' antid onie-hallf of the interveut riclar , inn; 2 ci VSl) iln the 'iept inlferior)l parlIotofte IIIIIsIIcar septuim. ; 5 cm drskiet ic area oni the Inferiorxvll infat l iniferl ior. wall; 2.5 cn VSI ) aidjaicent to tlhe inferiorXl walil. Occlusio of the left matin cortonary oterv;inormal dnonniian:1t right t(oonary artery; massive inifarc(t ioni of tihe init erlvenitricuilar sept urn with a septastl rop}t re 2.5 cmn inl diameter: iio.noirul fiee wall of t he left veit idle.

summarized in table 4. Marked dilatation of the right ventricle was a salient feature in all the patients. It is of interest that the left atrium was enlarged in only one patient. Figure 1 illustrates the aortic root and the normal sized left atrium in patient WF. An unusual pattern of mitral valve movement was seen in this patient (fig. 2). The mitral valve was seen to close completely shortly after it opened in diastole, and the valve then reopened almost completely. A markedly dilated right ventricle was present. Figure 3 shows the echocardiogram of patient SK. The tricuspid valve is seen within the dilated right ventricle. The direction of septal motion was normal in all three patients.

mitral regurgitation is not always easy. In Selzer's series of ten cases, the murmur of septal rupture was apical or was of equal intensity at the apex and the left sternal border in half the cases.'2 In one of our patients (DW) a harsh mid-systolic murmur was equally as loud at the apex as at the left sternal border. The diagnosis of septal perforation in this patient could not be made confidently on clinical grounds. Dilatation of the right ventricle was a consistent echocardiographic feature in all three patients. This is readily explained on the basis of combined volume and pressure overload of the right ventricle. In contrast, the echocardiographic right ventricular dimension was normal in four patients with pulmonary edema and acute mitral incompetence complicating myocardial infarction, studied in our laboratory (fig. 4) (unpublished data). Thus, the presence of right ventricular dilatation on the echocardiogram may be useful in differentiating between septal rupture and acute mitral regurgitation in the setting of an acute myocardial infarct. The unusual pattern of mitral valve movement seen in patient WF may also be of some diagnostic significance. Complete closure of the valve after its initial opening early in diastole may be explained by very rapid ventricular filling producing a steep rise in the left ventricular diastolic pressure. The valve then reopens almost completely. This probably denotes torrential flow through the mitral valve.

Discussion Rupture of the interventricular septum is an uncommon complication of myocardial infarction, which carries an ominous prognosis. It occurs in 0.5 to 1% of cases of acute myocardial infarction.9 In one series only 11W¼ survived more than two months.`'

_

The characteristic physical signs of septal rupture holosystolic murmur best heard at the left sternal border, without radiation to the axilla; and a systolic thrill in 50% of cases.1' The electrocardiogram freqiuentlv shows conduction disturbances. In contrast, acute mitral regurgitation due to myocardial infarction is usually associated with a systolic murmur that is best heard at the apex. However, the clinical differentiation between septal rupture and acute

_

-

---

-

-

consist of a

cw

RVO AW Ao

ECG -

PW Ao

Table 4

LA

Echocardiographic Findings Patient

{V (cm)

L\ V1 T)EI,.(cm) (em)

WF DW SK

83) 2.7 3.2

4.8 5.2 .5.4

Direction of

septal motion

38.5

Normnal

4.2

No1 rll"ll

2.8

Nor.mal

Figure 1 ',f'/ilfJatt(rihogroio of patient W'P), slouiting the aortic root atint the left atrium. (CW (bcest ictall; 10 right uentrieulatr otiflowu tract; AW Ao anttatenor*of ll taorta; I'l' Xo posterior tuall of aorta; =

Abbreviation: dimension.

YBE1)

left ventricslar enid-diastolic

=

IA

=

=

left atrium.

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ULTRASOUND IN VENTRICULAR SEPTAL RUPTURE

509

RV

'vs

PMV

,__w

~

Pl ~~~~PLV

Figure 2 Itirasoii nd recordtlmg fromin patient n XFI illistratitig tihe dilated rig/it ce tntritre aan1d tih cabi)iorrnal pa t t rin of iiiotc i letnt of asep the initril tl/. (-'X ( e tiest ra/tll; RVX riglit ut itrit le, IXllS inteiietricidart ()1(=troc ardliograiteii. t n leaflet of mitral calue,; PI .AiV antrior leaflet alo mitral value; PXp1p osteror posterior wall of left centricle. =

r_

q

{

t~

~

~ ( A ~~

01

"M

1 --

V*.

1,

RV

'vsa.

'vs

f-

PLV

Echotardiograom

of

patiteiit SK

dtemonstrating

venitri(ele (IlV) atiil thte tricenspid alvue (TV'). PL' left ientriele IS = ititererntrieciltr septunrn.

Circulation, Volume

5/,

the

=

dilated

rig/ht

/osterior watl of

1

'

',s--4,, --r

t"Apj

LVPW ,a-

Figure 3

-

1

.

Figure 4 E t'hoetariltogramn from ti patient tvit/i aeiite mitral incotmipeteite n ient (f cotmtplicatitiuig iioatirtlitil infarction. Thiere is exet iemotV the irnterueintri(eniltr septoi ([VS) arti dilatatioro of the left venitrioles. 'I1ie rig/it ix ii triciiltar dimnwrsion is iioro1ial. IXPXXW p)osterior ittill t)f left eiitrle

March 1975

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510

CHANDRARATNA ET AL.

The left atrial diameter was slightly increased in one patient and was within normal limits in the other two. These findings are consistent with poor compliance of the left atrium in the acute situation. In summary, the echocardiographic findings in three patients with ventricular septal rupture complicating acute myocardial infarction are presented. Since the complication cannot always be distinguished from acute mitral regurgitation, the echocardiogram may provide useful clues in support of this diagnosis. References 1. EDLER I, HERiTZ CH: Use of ultrasonic reflectoscope for continuous recording of movements of heart walls. Kungl Fysiogr Sallad i Lund Forhandl 24: 5, 1954 2. Popp RL, WOLFE SB, HIRATA T, FEIGENBALui H: Estimation of right and left ventricular size by ultrasound. A study of the echoes from the interventricular septum. Am J Cardiol 24: 523, 1969 3. HIRATA T, WOLFE SB, PoPP RL, HELMEN CH, FEIGENBAuIJ H:

The estimation of left atrial size using ultrasound. Am Heart J 78: 43, 1969 4. FEICENBALuNI H: Echocardiography. Philadelphia, Lea and Febiger, 1972, p 216 5. PoPP RL, BROwN. OR, SILVERHNIAN JF, HARRIsoN DC: Echocardiographic abnormalities in the mitral valve prolapse syndrome. Circulation 49: 428, 1974 6. SHIAH PM, GRANIIAK R, KRAfMER DH: Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy. Circulation 40: 3, 1969 7. JOYNEER CR, REID JM, BOND JP: Reflected ultrasound in the assessment of mitral valve disease. Circulation 27: 503, 1963 8. DIAvsOND MA, DILLON JC, HAINE CL, CHANG. S, FEIGENBALUX H: Echocardiographic features of atrial septal defect. Circulation 43: 129, 1971 9. DUGALL JC, PRYOR R, BLOLNT SC: Systolic murmur following myocardial infarction. Am Heart J 87: 577, 1974 10. LEE WY, CARDON L, SLODSKI S: Perforation of infarcted interventricular septum. Arch Intern Med 109: 731, 1962 11. FRIEDRBEBC. CK: Diseases of the Heart. Philadelphia, WB Saunders, 1966 12. SELZER A, GERBODE F, KERTH WJ: Clinical hemodynamic and surgical consideration of rupture of ventricular septum after myocardial infarction. Am Heart J 78: 598, 1969

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Echocardiographic observations on ventricular septal rupture complicating acute myocardial infarction. P A Chandraranta, P K Balachandran, P M Shah and M Hodges Circulation. 1975;51:506-510 doi: 10.1161/01.CIR.51.3.506 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1975 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539

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Echocardiographic observations on ventricular septal rupture complicating acute myocardial infarction.

Echocardiograms were performed on three patients with ventricular septal rupture complicating myocardial infarction. The pulmonary artery mean pressur...
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