Post-infarction ventricular septal rupture: a fatal mechanical complication of late-presenting STEMI - a case report

Introduction: Mechanical complications of myocardial infarction have become rare since the advent of percutaneous coronary intervention, but their occurrence remains associated with a high mortality rate. In the presence of suggestive clinical signs, unexplained hemodynamic instability, or specific risk factors, bedside echocardiography is essential to establish the diagnosis and to guide the optimal management strategy. Case presentation: We report the case of a 72-year-old man admitted for a late-presenting inferior ST-elevation myocardial infarction in whom coronary recanalization failed. Forty-eight hours after admission, the patient developed recurrent chest pain, ST-segment re-elevation and progressive cardiogenic shock. A second coronary angiography was first performed and was superimposable with the first. The diagnosis was subsequently established on bedside echocardiography, which revealed a massive apical ventricular septal rupture, leading to emergency surgical repair without prior mechanical circulatory support. The patient died from refractory cardiogenic shock and multiple organ failure. Conclusions: This case highlights the diagnostic pitfalls of post-infarction ventricular septal rupture, the value of repeated bedside echocardiography in patients with suspected mechanical complications, and the controversy regarding emergency surgical repair without prior hemodynamic stabilization by mechanical circulatory support.