Following a successful primary PCI for anterior STEMI, a 55-year-old man develops a new holosystolic murmur at the lower left sternal border on day 5. He is hypotensive and tachycardic. Echocardiography shows a left-to-right shunt. What is the most likely diagnosis and initial stabilizing intervention?
- A Ventricular septal rupture; intra-aortic balloon pump for hemodynamic support ✓
- B Papillary muscle rupture causing acute MR; emergent mitral valve repair
- C Free wall rupture with pericardial tamponade; pericardiocentesis
- D Right ventricular infarction; aggressive IV fluid loading
Correct answer: A. Ventricular septal rupture; intra-aortic balloon pump for hemodynamic support
Explanation
Post-MI ventricular septal rupture (VSR) typically occurs 3–7 days after STEMI (slightly earlier with thrombolytic therapy), presents with new holosystolic murmur and hemodynamic collapse, and is confirmed by echocardiography showing a left-to-right shunt through the interventricular septum. Stabilization with intra-aortic balloon pump reduces afterload and decreases shunt fraction before definitive surgical repair. Free wall rupture causes tamponade without an intracardiac shunt; papillary muscle rupture causes acute severe MR.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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