Delayed Ventricular Septal Rupture after Percutaneous Coronary Intervention in Acute Myocardial Infarction
A 70-year-old female had chest pain for three days prior to admission as well as hemiplegia and dysarthria for 5 days. She was referred to our hospital for aggravating chest pain. At the previous hospital, she was admitted for the treatment of type 2 diabetes mellitus and tentorial ischemia. Four years ago, she was diagnosed as mucinous ovarian cystadenoma and underwent bilateral oophorectomy and total hysterectomy. She has no history of smoking or alcohol use. Her father had a history of cardiogenic shock.\nOn admission, the pulse was 112 beats per minute, the respiration 20 per minute, the blood pressure 120/70 mmHg and the body temperature 36℃. The patient was alert at the time of admission. However, she appeared to be acutely ill, and presented with pale conjunctiva and non-icteric sclera. There was no jugular vein distension, and the heart rhythm was irregular without S3 or heart murmur. The lung was clear without rale or crackles. The level of initial CK was 282 IU/L (normal 0~185), CK-MB was 19.2 ng/mL (normal 0~5.0), and TnT was 1.93 ng/mL (normal 0~0.01), and these levels decreased following admission. Hs-CRP level was 2.88 mg/dL (normal 0~0.4). WBC count was 15,800/µL (normal 4000~10,000), and neutrophil count 78.9% (normal 42.2~75.2%). The glucose level was 279 mg/dL and LDL-cholesterol level 157 mg/dL. Other blood chemical and enzyme levels were normal. The urine was normal. On the initial electrocardiogram, 3 mm ST segment elevation in leads V2 through V4 and Q wave in lead II, III, and aVF was observed (). The chest X-ray revealed no abnormalities (). On transthoracic echocardiography, the estimated left ventricular ejection fraction was 45%. There was severe hypokinesia of the cardiac apex and along the inferior wall with moderate pulmonary hypertension (right ventricular systolic pressure was estimated as 55 mmHg). No mural thrombus was seen. She was given conservative care with medications consisting of heparin, IV nitrate, clopidogrel, and aspirin.\nOn the fourth inpatient day, coronary angiography and PCI was performed. From the coronary angiography, 70% and 90% stenosis was observed on the proximal and mid--portion of the LAD, respectively. Ninety percent stenosis on the 2nd obtuse marginal branch was also observed (). PCI with stent implantation for LAD lesions was successful ().\nOn the seventh inpatient day, the patient experienced dyspnea but her heart rhythm was regular and no cardiac murmur was heard. The lung sounds were not coarse but fine crackles were heard at both lung bases. The chest radiograph revealed pulmonary congestion on both sides (). The patient was treated with diuretics, and she managed well.\nOn day 20, her heart rhythm was regular but a grade 4/6 pansystolic murmur was heard at the mid-left sternal border. Echocardiography revealed improved wall motion of the anterior wall and the cardiac apex, but a ventricular septal defect approximately 1.3 cm in diameter was observed at the apical septum (). Because she did not show any serious symptoms related to the ventricular septal rupture and was nearly bed-ridden due to right hemiplegia as a sequel of cerebral infartion, only medical treatment was done. One month after discharge, she complained of dyspnea, and the chest radiograph showed pulmonary congestion with bilateral pleural effusion, but transthoracic echocardiography revealed normal wall motion of the cardiac apex and no change in the size of the defect. The diuretic dose was adjusted and she managed well. After 11-months of medical therapy, she died of an unknown cause.