Postinfarction Ventricular Septal Rupture Clinical Presentation

Updated: Sep 17, 2021
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Dale K Mueller, MD  more...
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Presentation

History and Physical Examination

Upon auscultation, a loud systolic murmur is heard, usually within the first week after an acute myocardial infarction (MI). The left-to-right shunt is often significant and can quickly compromise the cardiopulmonary system. There is sudden overload of the right ventricle and pulmonary arteries, resulting in increased pulmonary venous return. This is the most consistent physical finding of postinfarction ventricular septal rupture (VSR). Before the development of the murmur, the patient may have been stable after the acute MI. Coincident with the onset of the murmur, the patient’s clinical course undergoes a sudden deterioration, with the development of congestive heart failure (CHF) and, often, cardiogenic shock.

The typical harsh systolic murmur is audible over a large area, including the left sternal border and apical area. It sometimes radiates to the left axilla, thereby mimicking mitral regurgitation (MR). A thrill is palpable in approximately 50% of patients.

Because of the sudden increase in right sided blood flow, the second heart sound is accentuated and one may even hear an S3. Depending on the size of the shunt, one may also see signs of right and left heart failure. Signs of cardiogenic shock are common, including cold and clammy skin, cool extremities, unpalpable pulses, hypotension, oliguria, and diffuse rales. If the right ventricle is compromised, one will see elevation in the jugular venous pressure, enlarged/pulsatile liver, and distal extremity swelling. Within a short time, signs of coagulopathy will appear.

Almost 50% of patients have recurrent chest pain.