key: cord-0809875-5azyjour authors: Ahmed, Taha; Nautiyal, Ashoka; Kapadia, Samir; Nissen, Steven E. title: Delayed Presentation of STEMI Complicated by Ventricular Septal Rupture in the Era of COVID-19 Pandemic date: 2020-08-19 journal: JACC Case Rep DOI: 10.1016/j.jaccas.2020.05.089 sha: 2c252f5cfe92226cd0e13134a7d9c34dfb7f2b7c doc_id: 809875 cord_uid: 5azyjour A significant concern in current coronavirus disease-2019 (COVID-19) pandemic era is delay in first medical contact in patients with ST-segment elevation myocardial infarction (STEMI), due to reluctance to visit the hospital. We report a case of delayed presentation of STEMI as ventricular septal rupture during the COVID-19 pandemic, a rare presentation in the current age of primary percutaneous coronary intervention. (Level of Difficulty: Beginner.) is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). On March 14, 2020, a 65-year-old man presented to the emergency department with shortness of breath. The current symptoms started gradually 3 days before and worsened, prompting him to call the emergency medical squad. On presentation, the patient had tachycardia (heart rate of 115 beats/min), normal blood pressure of 117/90 mm Hg, tachypnea (respiratory rate of 24 breaths/min), and a temperature of 98.2 F. Physical examination revealed the patient to be in respiratory distress, and a grade 3/6 holosystolic murmur was heard over the left sternal border on chest auscultation. The electrocardiogram (ECG) revealed ST-segment elevation in leads II, III, and aVF with small Q waves (Figure 1 ). High-sensitivity troponin was elevated to 1,506 ng/l (normal <12 ng/l), and the patient was immediately transferred to the cardiac catheterization laboratory. Past medical history was significant for a 60-packyear history of cigarette smoking. He had not seen a physician for many years and had no prior cardiac evaluation. The patient recalled an episode of severe left-sided chest pain while performing push-ups Patient-based anxiety and concerns of contracting COVID-19 in the hospital is delaying as well as decreasing the timely presentation and interventions for emergencies such as ST-segment elevation myocardial infarction. Delayed presentations of ST-segment elevation myocardial infarction such as a ventricular septal rupture is a very rare presenting encounter, but in the current era of the COVID-19 pandemic, the incidence of this catastrophic complication as a delayed presenting complaint may increase. 7 days before admission, which resolved after he stopped. He was reluctant to visit the hospital and getting exposed to the ongoing viral pandemic, hence stayed at home, and the pain abated on its own. Family history was also remarkable for heart disease in both parents in their 50s. Differential diagnosis incudes ST-segment elevation myocardial infarction (STEMI), takotsubo cardiomyopathy, acute pericarditis/myocarditis, hyperkalemia, pulmonary embolism, and Prinzmetal's angina. Repeat ECG revealed persistence of ST-segment elevation with Q waves in leads II, III, and aVF. Complete blood count and basic metabolic panel were unremarkable. N-terminal pro-B-type natriuretic peptide was elevated to 3,231 pg/ml (normal <125 pg/ml). Creatine kinase and creatine kinasemyocardial band fractions were within normal limits, and troponin T was elevated to 1.2 ng/ml (normal 0 to 0.029 ng/ml) and trended downward on repeat testing. Coronavirus testing via nasopharyngeal swab was negative. Left heart catheterization revealed a completely occluded right coronary artery (RCA) at the midsegment (Video 1). Because no antiplatelet agents were administered before the catheterization, the patient was maintained on a bivalirudin drip. The RCA lesion was difficult to cross because the lesion appeared hard and fibrotic, but eventually, the lesion was successfully crossed, and a wire placed in the distal RCA. Owing to the difficulties encountered while crossing, it was elected to perform balloon angioplasty with the smallest balloon available. Three inflations were performed using a 1.5 Â 10-mm balloon with no change in the intraprocedural ECG. Dye injection with balloon pullback revealed extravasation of contrast involving what appeared to be the trabeculae of the right ventricle, with delayed washout (Video 2). Bivalirudin was discontinued, and 50 mg of intravenous protamine administered. Repeated injections were administered, and eventually after 10 min, no further extravasation was noted. The patient was hemodynamically stable with no hypotension, chest pain, arrhythmias, or heart block. The electrocardiogram on presentation shows ST-segment elevation in leads II, III, and aVF with small Q waves. Table 1) . The case was concluded, the PA catheter was VSR is a devastating complication following acute MI, and its incidence has decreased from 1% to 3% following STEMI in the pre-reperfusion era to 0.17% to 0.31% following primary percutaneous coronary (6). The patient was transferred to the cardiac intensive care unit, and an intra-aortic balloon pump was Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic Ventricular septal rupture complicating acute myocardial infarction: a contemporary review Trends in the clinical and pathological characteristics of cardiac rupture in patients with acute myocardial infarction over 35 years Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry Surgical repair of ventricular septal defect after myocardial infarction: outcomes from the Society of Thoracic Surgeons National Database ST-segment elevation myocardial infarction, ventricular septal rupture APPENDIX For supplemental videos, tomographic angiography reveals 2.5-cm ventricular septal rupture in the mid-inferoseptum with thinning of the basal and mid-inferior wall and inferoseptum in the axial, coronal