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Background
Ventricular septal defect (VSD) is an important and often fatal consequence of myocardial infarction (MI). We present an atypical case of a postinfarct VSD with a late presentation. In the era of primary coronary intervention and advancements in peri MI therapy, the incidence of complications, such as VSD, has decreased significantly. Delayed or indeed misdiagnosis can occur as a result of low clinical suspicion and an unfamiliarity with atypical presentations. This case serves as an important reminder of potentially fatal sequelae of MI and VSD, thus allowing for prompt recognition and early intervention.
Case presentation
A 78-year-old man presented with a 5-day progressive history of vomiting, dyspnoea and fever. He denied any history of chest pain. He had no significant medical history or family history and was on no regular medications. He had smoked variable amounts of cigarettes in the past.
On examination, he was febrile, tachycardic, hypotensive and peripherally cyanosed. There was a systolic murmur in the left lower sternal area. The patient deteriorated over 4 days with a multiple organ dysfunction syndrome and was managed in the critical care unit.
Investigations
Blood tests revealed raised inflammatory markers (white cell count of 15x109 /l and C reactive protein of 110 mg/l), a compensated metabolic acidosis, deranged liver function and evidence of acute kidney injury. The troponin I was 3.11 ng/ml (<0.04 ng/ml).
The ECG showed sinus tachycardia with T wave flattening in the inferior leads and T wave inversion in lead V6 ( figure 1 ). There were no ST segment changes or pathological Q waves and therefore no ECG evidence of transmural infarction. The chest radiograph had a small right-sided pleural effusion with no obvious pulmonary congestion.
Preoperative coronary angiography demonstrated a dominant right coronary artery (RCA) with complete mid-vessel occlusion after the right ventricular branch. The left coronary artery showed a severe segment of atheroma in the mid left anterior descending (LAD) artery. The circumflex was a small calibre vessel with no significant flow limiting lesions ( figure 2 ).
An initial technically difficult echocardiogram (due to tachycardia and patient being in extremis) showed an inferoseptal ventricular aneurysm, with no colour flow seen to cross between the left and right...