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SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Ventricular septal rupture (VSR) is an uncommon but fatal mechanical complication of Myocardial infarction (MI) The event occurs 2-8 days after infarction and often precipitates cardiogenic shock The incidence of Postinfarct VSR had declined over the years due to early reperfusion capabilities but is a surgical emergency even if the patients are hemodynamically stable CASE PRESENTATION: An 87 years old Caucasian woman with a known history of hypertension and arthritis presented to the emergency department with non-exertional epigastric, non-radiating sharp chest pain for the past several days The patient states that her chest pain was relieved by sublingual nitroglycerine The patient stated that she was scared to come to the ED, as she doesn’t want to catch COVID-19 from the hospital The patient denied any shortness of breath or palpitation Physical Examination was unremarkable Laboratory data on admission were noted for WBC – 15 19 cells/mcL, D-Dimer 3 08 mg/L, and Troponin 3 66 ng/ml and 30 ng/ml in 2nd recheck EKG showed normal sinus rhythm with T wave inversion in the lateral leads (Figure 1) The patient was initiated on a heparin drip according to ACS protocol and titrated with aPTT results A loading dose of aspirin was received with atorvastatin 40mg and metoprolol tartrate 25mg BID Cardiology was consulted, and subsequently, cardiac catheterization showed significant stenosis of LAD s/p placement of Drug-eluting stent (Figure 2) She was given DAPTs (Aspirin 81mg + Clopidogrel 75mg daily) post-PCI Echocardiogram showed a reduced ejection fraction (EF) 35-40% with wall motion abnormality on LAD territory Few hours post-cardiac catheterization, the patient acutely decompensated and became less responsive Her lab data were showing acutely worsening of leukocytosis 23 48 cells/mcL, Na 147 mmol/L, Creatinine 2 40 mg/dl, and troponin 96 1ng/ml EKG found out new ST-T waves abnormality in the anteroseptal and lateral leads Stat Echocardiogram showed a new membranous ventricular septal defect (Figure 3) The patient developed a cardiogenic shock, requiring three vasopressors (Epinephrine, dobutamine, and vasopressin) but continued to deteriorate and triggered code blue The family was notified for the goal of care and switched for palliative care before the patient passes away DISCUSSION: Risk factors for higher mortality from acute VSD are female sex, advanced age, arterial hypertension, anterior wall AMI, absence of previous AMI, and late arrival at the hospital Surgical repair for VSR should be carried out on an emergency basis, even if the patient is hemodynamically stable CONCLUSIONS: VSR is a surgical emergency but patients who develop VSR with multiorgan failure may not be a candidate for surgery and should consider palliative care Reference #1: Serpytis P, Karvelyte N, Serpytis R, Kalinauskas G, Rucinskas K, Samalavicius R, et al Post-infarction ventricular septal defect: risk factors and early outcomes Hellenic J Cardiol 2015 Jan-Feb 56(1):66-71 Reference #2: Crenshaw BS, Granger CB, Birnbaum Y, et al Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators Circulation 2000;101: 27-32 Reference #3: Stolt V, Cook S, Raber L, et al Amplatzer Septal Occluder to treat iatrogenic cardiac perforations Catheter Cardiovasc Interv 2012 Feb 1 79(2):263-70 DISCLOSURES: No relevant relationships by Ameenjamal Ahmed, source=Web Response No relevant relationships by Avan Aljaf, source=Admin input No relevant relationships by Salem Gaballa, source=Web Response No relevant relationships by Kyaw Hlaing, source=Web Response No relevant relationships by Jane Lindsay, source=Web Response No relevant relationships by Safa Moursy, source=Web Response no disclos re on file for Asamoah Owusu;No relevant relationships by kashyap patel, source=Web Response No relevant relationships by Brijesh Patel, source=Web Response
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