Five days after an anterior STEMI, a 65-year-old man develops sudden onset dyspnoea and hypotension. Examination reveals a loud harsh pansystolic murmur at the left sternal border with a systolic thrill. Echocardiography shows a left-to-right shunt. The most likely complication and definitive management are:
- A Acute mitral regurgitation — emergency mitral valve repair
- B Ventricular septal defect — surgical or percutaneous closure after haemodynamic stabilisation ✓
- C Free wall rupture — emergency pericardiocentesis
- D Right ventricular infarction — IV fluids and atropine
Correct answer: B. Ventricular septal defect — surgical or percutaneous closure after haemodynamic stabilisation
Explanation
Post-infarction ventricular septal defect (VSD) classically presents 3–7 days after anterior MI with a new harsh pansystolic murmur and systolic thrill; echocardiography confirms a left-to-right shunt. Emergency surgery carries high mortality; haemodynamic stabilisation with intra-aortic balloon pump followed by definitive closure is the standard approach. Acute MR also causes a murmur but does not produce a shunt on echo, and free wall rupture leads to tamponade.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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