Circulation, Vol 74, 45-55, Copyright © 1986 by American Heart Association
CA Moore, TW Nygaard, DL Kaiser, AA Cooper and RS Gibson
Over a 5.5 year period, 1264 consecutive patients with acute myocardial
infarction as confirmed by enzyme levels were prospectively identified. Of
these, 25 (2%) suffered ventricular septal rupture (pulmonary/systemic flow
range 1.5 to 6) 7 +/- 7 days after onset of myocardial infarction. Death
occurred in 14 patients (56%) and was more common after inferior than
anterior myocardial infarction (11 of 15 [73%] vs three of 10 [30%], p less
than .05). Among 133 variables analyzed, survivors and nonsurvivors were
similar with respect to all premorbid clinical characteristics, infarct
size as assessed by peak creatine kinase values, shunt size,
two-dimensional echocardiographic and hemodynamic indexes of left
ventricular function, and extent of coronary disease. Compared with
survivors, the nonsurvivors had greater impairment of right ventricular
function as determined by a higher two- dimensional echocardiographically
derived right ventricular wall motion index (RVWMI) (0.55 +/- 0.87 vs 1.70
+/- 0.45, p less than .001), greater elevation of right ventricular
end-diastolic pressure (11 +/- 6 vs 17 +/- 6, p less than .02), and greater
mean right atrial pressure (10 +/- 6 vs 16 +/- 3, p less than .01). Of
interest, two of the three patients who presented with anterior myocardial
infarction and who died had inferiorly extended infarcts and all had
abnormal RVWMIs (greater than or equal to 1.0). As expected, cardiogenic
shock shortly after onset of ventricular septal rupture was associated with
a 91% mortality, but was more common after inferior than anterior
myocardial infarction (60% vs 20%, p less than .05). The mean effective
cardiac index was also higher in survivors than nonsurvivors (2.1 +/- 0.5
vs 1.2 +/- 0.5, p less than .001). Finally, multivariate analysis indicated
that all nonsurvivors could be identified based on: an effective cardiac
index of 1.75 liters/min/m2 or less, the presence of extensive right
ventricular and septal dysfunction on the two- dimensional echocardiogram,
a mean right atrial pressure of 12 mm Hg or more, and early onset of
ventricular septal rupture. Thus, our data demonstrate that: mortality is
higher when ventricular septal rupture complicates inferior than when it
complicates anterior myocardial infarction, survivors can be distinguished
from nonsurvivors and the prediction of outcome is highly accurate, and
combined right ventricular and septal dysfunction has a substantial impact
on prognosis.
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Postinfarction ventricular septal rupture: the importance of location of infarction and right ventricular function in determining survival
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