A 70-year-old man 48 hours post-inferior STEMI develops a new pansystolic murmur at the left sternal border with a thrill, and acute decompensated heart failure. Echocardiogram shows a 1.5 cm VSD in the basal interventricular septum with left-to-right shunt. Which statement about the management of post-MI VSD is correct?

• A Emergency surgical repair should be performed within 24 hours regardless of hemodynamic stability
• B Percutaneous VSD closure is the preferred definitive treatment in all cases
• C Hemodynamic stabilization with IABP/MCS followed by surgical repair at 3-4 weeks gives best survival ✓
• D Medical management with afterload reduction is sufficient in basal VSDs

Explanation

Post-infarction VSD is a mechanical complication with high mortality. Current evidence (including data from the GUSTO-I trial and registry data) supports that in hemodynamically stable patients, delaying surgery 3–6 weeks allows infarct margin fibrosis, improving suture hold and reducing operative mortality from ~50% in acute to ~20% in delayed repair. IABP or percutaneous mechanical circulatory support bridges patients to definitive repair. Emergency surgery is reserved for cardiogenic shock unresponsive to stabilization. Afterload reduction alone is inadequate.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.