Ventricular Septal Rupture Despite Early Pharmaco-Invasive Reperfusion in Anterior STEMI With Favorable Surgical...

Ventricular septal rupture (VSR) is a rare but catastrophic mechanical complication of acute myocardial infarction, even in the contemporary reperfusion era. Although early reperfusion strategies have significantly reduced its incidence, they do not completely eliminate the risk. We report the case of a 76-year-old man with a history of hypertension and no prior structural heart disease who presented with an anterior ST-elevation myocardial infarction (STEMI). He received tenecteplase 2 hours and 37 minutes after symptom onset and was subsequently referred for routine percutaneous coronary intervention (PCI), during which a stent was implanted in the left anterior descending (LAD) artery. During in-hospital monitoring, a new harsh holosystolic murmur was detected. Transthoracic echocardiography revealed an 11-mm interventricular septal defect with left-to-right shunting, which was confirmed by color and spectral Doppler. Despite this mechanical complication, the patient remained hemodynamically stable and did not require vasopressor support. He underwent successful surgical repair using an infarct exclusion technique with a bovine pericardial patch. The postoperative course was favorable, with no need for mechanical circulatory support, extubation within the first 12 hours, no requirement for high-dose vasoactive amines, and no residual shunt on follow-up echocardiography. He was discharged home with outpatient follow-up. This case highlights that post-infarction VSR may occur despite timely pharmaco-invasive reperfusion, particularly in anterior STEMI, and underscores the importance of continued clinical vigilance even after apparently successful reperfusion. Early recognition through physical examination and echocardiography, together with prompt multidisciplinary management, may allow for favorable outcomes in selected patients.