CTICasesPost-infarction Ventricular Septal Defect
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Imaging findings
Contrast-enhanced CT of the chest demonstrates altered perfusion at the level of the interventricular septum, with a normal caliber of the main pulmonary arteries and no pulmonary embolism. Multiplanar reconstructions and subsequent cardiac MRI reveal an apparent communication measuring less than 1 cm at the level of the inferior basal septum between the left and right ventricles, representing a left-to-right shunt. Pre-contrast and cine MRI demonstrate increased signal of the involved myocardium, hyperintensity, and associated hypokinesis/dyskinesis in the distal LAD territory, along with transmyocardial late gadolinium enhancement consistent with an acute myocardial infarction. The right ventricle is also noted to be dilated with distension of the main and branch pulmonary arteries, indicating right-sided volume overload.
Key takeaways
Post-infarction ventricular septal defect (VSD) or ventricular septal rupture is an uncommon mechanical complication of acute myocardial infarction, typically occurring in the setting of a transmural infarction. While they carry an extremely high mortality rate (up to 80% if untreated), immediate surgical or percutaneous closure is often required. However, clinical management can be challenging because a fragile, acute septum may not easily support an Amplatzer closure device, forcing clinicians to balance the risk of early intervention on fragile tissue against the risk of rapid clinical deterioration from acute congestive heart failure.
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