key: cord-0817518-ojpnp38g
authors: Parikh, Malav; Busman, Meredith; Dickinson, Michael; Wohns, David; Madder, Ryan D.
title: Ventricular Septal Rupture in 2 Patients Presenting Late after Myocardial Infarction during the COVID-19 Pandemic
date: 2020-09-23
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2020.07.023
sha: f2b316a7767764c054b2095a1f4dae1df9470827
doc_id: 817518
cord_uid: ojpnp38g

Ventricular septal rupture (VSR) following myocardial infarction is rare in the reperfusion era. The decrease in patients presenting with myocardial infarction during the coronavirus-2019 (COVID-19) pandemic could result in more frequent VSR. This report describes two patients with VSR presenting late after myocardial infarction and treated at a single institution. (Level of Difficulty: Beginner.)

M echanical complications of myocardial infarction are rare in the reperfusion era (1, 2) . During the coronavirus-2019 (COVID-19) pandemic, reports of presentations of ST-segment elevation myocardial infarction (STEMI) have decreased (3) . It is therefore conceivable mechanical complications might have become more prevalent. This report describes 2 patients with ventricular septal rupture (VSR) treated at a single center during the pandemic.

A 67-year-old male presented with 5 days of epigastric pressure and dyspnea. He initially resisted seeking care after symptom onset due to fear of contracting COVID-19 infection. Initial vital signs were blood pressure of 143/63 mm Hg, heart rate of 118 beats/min, and respirations of 26 breaths/min. He was diaphoretic with mottled extremities. Electrocardiography showed inferior Q waves. Result for COVID-19 infection testing was negative. Coronary angiography demonstrated an occluded right coronary artery, and echocardiography demonstrated a VSR ( Figure 1 ). Venoarterial extracorporeal membrane oxygenation was initiated. Due to progressive multiorgan failure, surgical and percutaneous VSR repair were deemed futile. He expired on day 7 of hospitalization.

A 60-year-old female presented with dyspnea 1 to 2 weeks after an illness characterized by chest pain and vomiting that she thought was a viral infection. Initial vital signs were blood pressure of 135/78 mm Hg, a heart rate 95 beats/min, and respirations of 20 breaths/min. Electrocardiography showed anterior Q waves. Coronary angiography revealed left anterior descending artery occlusion, and echocardiography revealed a VSR Manuscript received May 1, 2020; revised manuscript received June 26, 2020, accepted July 7, 2020. ( Figure 1 ). An intra-aortic balloon pump was placed. Percutaneous VSR closure was performed, but she developed apical extension 4 days later (Figure 1) , which was treated with open surgical repair. She ultimately progressed to hospital discharge.

This report describes 2 late-presenting myocardial infarctions complicated by VSR. It is notable that the COVID-19 pandemic seemingly influenced each patient to avoid seeking immediate care after symptom onset. At the time of this writing, the authors were aware of 3 additional VSR cases treated during the pandemic at our institution. Historically reported to occur in 0.21% of hospitalizations for STEMI (1) Twitter: @RyanMadderMD. 

Temporal trends and outcomes of mechanical complications in patients with acute myocardial infarction

Ventricular septal rupture complicating acute myocardial infarction: a contemporary review

Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic

KEY WORDS mechanical complication, myocardial infarction, STEMI, ventricular septal defect, ventricular septal rupture

Ventricular Septal Rupture