A 62-year-old male has an anterior STEMI. Primary PCI is performed at 90 minutes. Post-PCI ECG shows persistent ST elevation and the patient develops hypotension and pulmonary oedema on day 2. Echo reveals an EF of 20%. What is the most likely mechanical complication?

• A Acute mitral regurgitation from papillary muscle rupture
• B Left ventricular free wall rupture
• C Ventricular septal defect
• D Left ventricular aneurysm ✓

Explanation

Persistent ST elevation after successful reperfusion, combined with severely reduced EF and signs of heart failure on day 2, is characteristic of a left ventricular aneurysm — a true aneurysm forming over the infarcted anterior wall. VSD and free wall rupture cause acute haemodynamic collapse and are typically lethal without immediate surgery. Papillary muscle rupture causes acute severe MR with a pansystolic murmur. LV aneurysm can also predispose to mural thrombus and systemic emboli. It is best confirmed by echocardiography showing dyskinetic wall motion.

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

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Written and medically reviewed by the StethoPrep medical team.