The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

LindseyR. Baden, M.D., Editor

Ventricular Septal Defect after Acute

Myocardial Infarction
A

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

B C

VSD

RV

LV
RA

LA

A
LeonardM. Rademakers, M.D., Ph.D. previously healthy 76-year-old man with a 1-week history of
LokienX. VanNunen, M.D. continuous chest pain presented to the emergency department with rapidly
Catharina Hospital progressive dyspnea on exertion. His blood pressure was 70/40 mm Hg,
Eindhoven, the Netherlands and he had signs of systemic hypoperfusion. Cardiac auscultation revealed a harsh
nard.rademakers@catharinaziekenhuis.nl holosystolic murmur, which was heard over the entire precordium. The electrocar-
diogram showed inferior ST-segment elevations that were consistent with acute or
subacute myocardial infarction (Panel A). Transthoracic echocardiography revealed
a left ventricle (LV) with overall preserved systolic function and inferior akinesis,
a dilated, severely impaired right ventricle (RV), and a large, sharply demarcated
Videos showing interventricular septal defect (VSD; Panel B, arrow; and Video 1) with a large,
a ventricular turbulent left-to-right transseptal flow (Panel C, and Video 2) (LA denotes left
septal defect
atrium, and RA right atrium). Coronary angiography revealed occlusion of the
are available
at NEJM.org right coronary artery. Emergency surgical intervention was performed because of
persistent cardiogenic shock despite supportive therapies, including intraaortic
balloon pump. Closure of the septal defect was not successful owing to the fragil-
ity of the infarcted tissue. The patient died from progressive heart failure.
DOI: 10.1056/NEJMicm1512579
Copyright 2016 Massachusetts Medical Society.

e28 n engl j med 374;23nejm.org June 9, 2016

The New England Journal of Medicine

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