Impact of cardiac magnetic resonance imaging in the management of post myocardial infarction ventricular septal rupture- a case report

A 61-year old man, a known diabetic and hypertensive, presented to us with worsening dyspnea of 25 days duration with pan-systolic murmur at left parasternal region without thrill. One month ago, he suffered from ST-segment elevation anterior wall myocardial infarction with window period of 24 hours. He was taken up for coronary angiography and subsequently, balloon angioplasty with thrombosuction of the left anterior descending coronary artery was done. He developed sudden onset of dyspnea on the 5th day of admission which progressed to NYHA class III dyspnea when he presented to us. Echocardiogram showed 8 mm ventricular septal defect near apex with left to right shunt with moderate tricuspid regurgitation and pulmonary artery hypertension. Cardiac magnet resonance imaging was performed, which provided detailed information on size and localization of the ruptured septum as well as viability of myocardium. It showed thinning of the myocardium and ballooning in the left ventricular apical region with moderate left ventricular systolic dysfunction. There was defect in the interventricular septum at the apical region of 18 10 mm. Moreover, MRI revealed that the ventricular septal rupture was within the myocardial infarction area, which was substantially larger than the rupture. Severe hypokinesia and greater than 75 late gadolinium enhancement was present in the LAD territory (middistal septum and apical regions) suggestive of non-viable myocardium. Subsequently, patient underwent successful surgical closure of the defect (a Gore-Tex patch closure) along with saphenous venous grafting to LAD. He was completely asymptomatic and in NYHA class I at 1 month of follow-up. Our case emphasizes the impact of cardiac magnetic resonance imaging in the management of such rare complication of acute myocardial infarction and its advantages over other imaging modalities.