Cardiac Septal Rupture (Ventricular Septal Rupture)

What happens in a septal rupture

During a heart attack, a blocked coronary artery starves part of the heart muscle of oxygen and it dies (infarction). Over the next several days, inflammatory cells clear the dead muscle before scar tissue forms. During this window, the weakened area is at its most fragile. If the infarct involves the septum, the wall can tear.

Because pressure is much higher in the left ventricle, blood rushes through the hole into the right ventricle and lungs. The left ventricle pumps less blood to the body, while the right side and lungs become overloaded. This causes sudden heart failure and often cardiogenic shock.

Risk factors

• a first, large heart attack
• delayed or no reopening of the blocked artery
• older age
• female sex
• high blood pressure
• heart attacks affecting the front (anterior) or lower (inferior) walls
• poor collateral blood supply

Other mechanical complications of a heart attack include rupture of the free wall of the heart and papillary muscle rupture causing severe mitral regurgitation.

Other causes

Rarely, septal rupture results from blunt chest trauma (such as a steering wheel impact; see heart contusion), heart surgery, endocarditis or certain cardiomyopathies. A ventricular septal defect present from birth is a different condition.

Symptoms

• sudden or rapidly worsening shortness of breath
• recurrent or ongoing chest pain
• dizziness, fainting or confusion
• cold, clammy, pale skin
• fast heart rate and low blood pressure
• reduced urine output

On examination, doctors often hear a new, loud, harsh murmur along the left side of the breastbone, sometimes with a palpable vibration (thrill).

Diagnosis

• Echocardiogram with color Doppler: shows the defect and the flow of blood across it; the key test.
• ECG and cardiac enzymes: confirm the heart attack.
• Right heart catheterization: a jump in oxygen levels between the right atrium and right ventricle confirms a left-to-right shunt.
• Coronary angiography to assess blocked arteries, often before surgery.
• Cardiac CT or MRI in stable patients.

Treatment

Stabilization

• Medicines to support blood pressure and reduce strain on the heart, such as vasodilators and inotropes.
• Mechanical circulatory support: intra-aortic balloon pump, Impella devices or ECMO to support circulation and reduce the shunt.
• Breathing support if needed.

Repair

• Surgical repair: closing the defect with a patch, often combined with bypass surgery for blocked arteries. Timing is a balance: immediate surgery is needed for unstable patients, while in some stable patients delaying surgery for days allows the tissue to firm up and improves the repair.
• Transcatheter closure: a device inserted through a blood vessel to plug the hole, used in selected patients or for residual defects after surgery.

Without repair, most patients die within days to weeks.

Outlook

Ventricular septal rupture remains one of the most dangerous heart attack complications. Even with surgery, mortality is high, often 40 percent or more in hospital, and worse in those with cardiogenic shock. People who survive repair generally do reasonably well long term with heart failure medicines, rehabilitation and follow-up.

Prevention

The most effective prevention is fast treatment of heart attacks:

• Call 911 immediately for chest pain or other heart attack symptoms.
• Do not wait or drive yourself.
• Prompt angioplasty or clot-busting medicine limits heart muscle damage and greatly reduces mechanical complications.

Frequently asked questions

What is a ventricular septal rupture?

It is a tear in the muscular wall between the heart's two lower chambers, usually caused by a heart attack that damaged that wall. Blood flows abnormally from the left to the right side, causing sudden heart failure and shock. It is a surgical emergency.

When does septal rupture happen after a heart attack?

It most often occurs 3 to 5 days after a heart attack, when the damaged muscle is weakest, but can happen within the first day or up to 2 weeks later. It is more likely after large heart attacks that were not treated quickly.

Can you survive a septal rupture?

Yes, with emergency treatment, but the risk is high. Surgery or catheter repair, along with mechanical heart support, saves many patients. Without repair, survival is very poor. Outcomes are better in people who are not in shock at the time of repair.

How can septal rupture be prevented?

The best prevention is getting emergency treatment for heart attack symptoms immediately. Rapidly reopening the blocked artery with angioplasty or clot-busting medicine limits muscle damage and has made septal rupture much less common.