VENTRICULAR SEPTAL RUPTURE: CROSSROADS BETWEEN POTENTIAL LIFESAVING MANAGEMENT AND PATIENT-CENTERED CARE

INTRODUCTION: Ventricular septal rupture (VSR) is a complication that can occur after an acute myocardial infarction (MI).Through the creation of reperfusion therapies, the incidence of this sequelae has decreased but carries a grave prognosis.Without intervention, 50% of patients die within one week and 80% within four weeks, while those who received surgical intervention have a 30-day mortality rate of approximately 47% (1).Typically, VSR occurs within one and five days of an MI, and risk factors include females, advanced age, and no previous smoking history (2). CASE PRESENTATION:A female in her 90s with a history of hypertension that presented after a syncopal episode.Over the previous few days, the patient endorsed diarrhea and vomiting.The initial laboratory assessment revealed a bicarbonate of 9, a lactic acid of 7, and an initial troponin of 5.The electrocardiogram unveiled ST-elevations in leads V4 and V5.A transthoracic echocardiogram revealed a reduced ejection fraction of 40% to 45% and hypokinesis in various wall segments.In addition, the patient had a significant VSR identified at the apex with a left-to-right shunt (figure 1 and 2) and severe pulmonary hypertension with a right ventricular systolic pressure of 83 mmHg.The patient was deemed to be a poor surgical candidate due to her advanced age, frailty, and multi-system organ failure and she stated that she did not want to proceed with any further treatment.The patient remarked that she was content with the idea of passing and seeing her husband, who had died seven years prior.As a result, the patient died later that day, surrounded by family.DISCUSSION: Although VSR is uncommon, clinicians need to be conscious of this potential complication in order to diagnose, treat, and appropriately prognosticate.In this case, the patient presented with risk factors associated with VSR: advanced age, female, and no previous smoking history.VSR carries a dismal prognosis as the creation of a left-to-right shunt, overloads the right ventricle and, subsequently, the pulmonary vasculature.This can rapidly lead to heart failure, pulmonary arterial hypertension, cardiogenic shock, and death.The definitive treatment is through surgical closure, which has been shown to improve outcomes compared to medical management alone (2).The 2013 American College of Cardiology and American Heart Association recommend emergent surgical repair regardless of hemodynamic status (3).With this in mind, effective communication between the clinicians and the patient, lead to de-escalation of care and comfort measures only.CONCLUSIONS: This case documents an atypical presentation of an MI as well as a rare complication.Although VSR can be treated surgically, these patients are often of advanced age with many comorbidities.As such, the overall prognosis remains poor even with intervention.This case serves an important reminder that while guidelines may recommend invasive and lifesaving treatment, clinicians must embrace patient autonomy and patient-centered care.Although this patient succumbed to her illness, she died with the emotional, mental, and spiritual support of the staff and family that surrounded her in her final moments.