Ventricular Septal Rupture and Right Ventricular Free
Wall Dissection after Inferior Myocardial Infarction:
A Case Report and Review of the Literature
Gernot Schram, MD, PhD, Btissama Essadiqi, MD, Michel Doucet, MD, Denis Bouchard, MD,
and Robert Amyot, MD, Montreal, Quebec, Canada
Ventricular septal rupture (VSR) with dissection of the right ventricular free wall is an extremely rare complica-
tion after inferior myocardial infarction. Mortality is 100% without surgical treatment. The optimal surgical
strategy remains unclear because of the limited number of cases, but repair of VSR alone might be equally
effective as repair of VSR and right ventricular free wall reconstruction. Transesophageal echocardiography
is an important adjunct to transthoracic echocardiography to establish the diagnosis. (J Am Soc Echocardiogr
Keywords: Ventricular septal rupture, Right ventricular free wall dissection, Transesophageal echocardiogra-
A 67-year-old man presented to our hospital in cardiogenic shock
with a history of intermittent epigastric discomfort in the previous 3
treated with nifedipine, ramipril, and metformin.
On arrival, the patient was pale and diaphoretic. Blood pressure
was 60/40 mmHg,heart ratewas 80 beats/min, anda 2-3/6 holosys-
tolic murmurwas audibleatthe cardiac apex.Jugular venouspressure
was elevated. Electrocardiography revealed high-degree atrioventric-
ular block and inferior ST-segment elevation with inverted Twaves in
the inferior and lateral leads. Troponin T, creatine kinase, and creatine
kinase-MB levels peaked at 20.35 mg/L, 1,372 U/L, and 140.4 mg/L,
respectively. Biochemistry showed acute renal failure, hepatic cytoly-
sis and lactic acidosis. Chest x-ray displayed pulmonary edema.
Treatment of cardiogenic shock was initiated immediately. Trans-
thoracic echocardiography was performed <2 hours after presenta-
tion and established inferior wall motion abnormalities and a 17 ?
24 mm ventricular septal rupture (VSR) of the basal and mid infero-
on color Doppler (Video 1B, Figure 1 bottom). The left ventricular
and severely hypokinetic. Moderate tricuspid regurgitation was pres-
ent, andsystolic pulmonary artery pressure was 70mm Hg. Coronary
angiography demonstrated occlusion of the distal right coronary
artery as well as intermediate lesions on the proximal left anterior
descending and circumflex coronary arteries.
The patient was stabilized after volemic resuscitation, positive ino-
tropic support, and the placement of an intra-aortic counterpulsation
pump. Emergency coronary artery bypass grafting of the left anterior
descending coronary artery and posterior interventricular artery was
performed, and the septal rupture was repaired with a pericardial
patch a few hours after admission. Transesophageal echocardiogra-
phy (TEE) during surgery unveiled an intramyocardial dissection of
the right ventricular inferior wall at the site of the VSR (Video 2,
Figure 2). The right ventricular free wall (RVFW) dissection was left
The postoperative evolution was favorable, with normalization of
pulmonary artery pressure and hemodynamic parameters. The
patient was dismissed 6 days after admission. At follow-up 1 month
charge revealed a thrombosis of the RVFW dissection and a repaired
VSR with no residual shunt (Videos 3A and 3B, Figure 3).
VSR with accompanying intramyocardial dissection of the RVFW is
an extremely rare complication in patients with inferior myocardial
infarction (MI)and was first described in 1977 in postmortem studies.1
We reviewed the 5 cases reported in the literature since this initial
description. Twomanagement strategies arepossible forintramyocardial
dissection, medical treatment only and surgical repair.
Although spontaneous closure of left ventricular intramyocardial
anterior MI2,3without VSR, mortality in patients with VSR and
RVFW dissection after inferior MI is 100% if treated medically.4-6
Surgical repair of VSR after MI improves survival, although mortality
rates remain high.7However, the optimal surgical strategy in patients
Tighe et al8reported two patients who developed VSR and RVFW
dissection after inferior MI and underwent emergent repair of both
VSR and RVFW. Postoperative evolution was favorable, and both
patients were well at follow-up. Another patient, treated in the same
From theDepartmentof Cardiology, Sacre-Coeur Hospital,Universityof Montreal,
Montreal, Quebec, Canada (B.E., M.D., R.A.); and the Montreal Heart Institute,
Montreal, Quebec, Canada (G.S., D.B.).
Reprint requests: Gernot Schram, MD, PhD, Montreal Heart Institute, 5000
Belanger Street East, Montreal, Quebec H1T 1C8, Canada (E-mail: gernot.
Copyright 2010 by the American Society of Echocardiography.
manner, died of hemorrhagic complications after surgery, possibly
related to thrombolysis administered at admission for inferior MI.9
In our patient, transthoracic echocardiography was suggestive of
RVFW dissection. TEE has been shown to have 100% sensitivity5
and in our case confirmed the diagnosis. At the surgeon’s discretion,
only repair of the VSR was performed, without reconstruction of the
RVFW. At 4-week follow-up, the patient was symptom free. Control
TEE showed a repaired ventricular septum without residual intracar-
diac shunt and partial thrombosis of the RVFW dissection. Only one
other case treated in the same way has been reported inthe literature,
with a comparable outcome at 6-month follow-up.10
value of the different surgical options is difficult to assess. Repair of
VSR is mandatory and significantly improves the outcome of post-
MI septal rupture, but the importance of RVFW reconstruction
remains debatable. Patients have fared well with and without that
intervention, and one must weigh the risks of prolonging the surgical
procedure and extracorporeal circulation exposure against the bene-
fits of repairing the RVFW.
is mandatory, but the value of RVFWreconstruction remains elusive.
1. Daubert JC, Mattheyses M, Fourdilis M, Pony JC, Gouffault J. Infarction of
theright ventricle.2. Prognosticandtherapeuticaspects[articlein French].
Arch Mal Coeur Vaiss 1977;70:257-64.
Figure 2 Transesophageal echocardiogram showing large
intramyocardial dissection of the RVFW from the apex to almost
the tricuspid annular level (arrow).
tion (small arrow) in the continuity of a large VSR of the basal to
mid inferoseptal wall (large arrow). Color Doppler (bottom)
shows a significant left-to-right shunt.
Figure 3 Transesophageal echocardiogram at 4-week follow-
up showing intramyocardial thrombosis of the RVFW (arrow).
Color Doppler shows no residual flow (bottom).
791.e2 Schram et al
Journal of the American Society of Echocardiography
2. Drozdz J, Kasprzak JD, Krzeminska-Pakula M. Spontaneous closure Download full-text
(thrombosis) of the intramyocardial dissection: 40-month follow-up.
J Am Soc Echocardiogr 2002;15:1023-4.
3. Sari I, Davutoglu V, Kucukdurmaz Z. Intramyocardial dissection after sub-
acute anterior wall myocardial infarction: an unusual form of myocardial
rupture with subsequent spontaneous healing. Echocardiography 2008;
4. Scanu P, Grollier G, Lamy E, Commeau P, Valette B, Lognone T, et al.
Myocardial dissection in infarction of the right ventricle. Clinical echocar-
diographic and pathological aspects [article in French]. Arch Mal Coeur
5. Maillier B, Metz D, Nazeyrollas P, Maes D, Chapoutot L, Jennesseaux C,
et al. Value of transesophageal echocardiography in post-infarction septal
ruptures [article in French]. Arch Mal Coeur Vaiss 1996;89:695-702.
6. Karhausen J, Nowak M, Couper GS, Formanek V, Mirakaj V, Locke A,
etal. Rightventriculardissectiondiagnosed on transesophageal echocardi-
ography. Anesth Analg 2008;106:412-4.
7. Pretre R, Ye Q, Grunenfelder J, Lachat M, Vogt PR, Turina MI. Operative
results of ‘‘repair’’ of ventricular septal rupture after acute myocardial
infarction. Am J Cardiol 1999;84:785-8.
8. Tighe DA, Paul JJ, Maniet AR, Flack JE, Mannionj JD, Rifkin RD, et al.
Survival in infarct related intramyocardial dissection importance of early
echocardiography and prompt surgery. Echocardiography 1997;14:
9. Ari H, Tiryakioglu O, Ari S, Bozat T, Koca V. A rare clinical entity: ventric-
ular septal rupture with right ventricular wall dissection after inferior
myocardial infarction. Echocardiography 2009;26:211-3.
et al. Septal rupture with right ventricular wall dissection after myocardial
infarction. Cardiovasc Ultrasound 2005;3:33.
Journal of the American Society of Echocardiography
Volume 23 Number 7
Schram et al 791.e3