Battling Right Ventricular Dysfunction in Post-Infarction Ventricular Septal Defect—A Case Report and Comprehensive Review of Literature

Post-infarction ventricular septal defect (VSD) represents a rare but frequently fatal mechanical complication of ST-elevation myocardial infarction (STEMI), associated with high morbidity and mortality despite advances in reperfusion strategies. The optimal timing of surgical repair remains a matter of ongoing debate, particularly in patients presenting with hemodynamic instability and evolving right ventricular failure. Two main strategies have been proposed: an early surgical approach aimed at preventing progressive hemodynamic deterioration and right ventricular dysfunction, and a delayed strategy that allows for infarct maturation and fibrotic remodeling of the septal margins, thereby facilitating more secure patch anchoring and reducing the risk of residual shunting. We report the case of a 39-year-old male with multiple cardiovascular risk factors who presented to the emergency department after seven days of persistent chest pain and was diagnosed with an inferior STEMI. Urgent percutaneous coronary intervention was performed, with successful stent implantation in the right coronary artery. Seven days later, transthoracic echocardiography identified an inferior post-infarction ventricular septal defect. In the context of clinical deterioration characterized by progressive right ventricular failure, urgent surgical repair was undertaken. The postoperative course was complicated by severe pulmonary hypertension and refractory cardiogenic shock, necessitating veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for five days. The patient was subsequently weaned successfully from mechanical circulatory support and discharged on postoperative day 12. At one- and three-month follow-up, he remained asymptomatic, with significant recovery of left ventricular ejection fraction. This case underscores the critical importance of timely surgical intervention in post-infarction VSD, particularly in the setting of right ventricular failure, and highlights the essential role of temporary mechanical circulatory support in the management of severe postoperative cardiogenic shock.