Hrev_master [page 12] [Emergency Care Journal 2025; 21:13573] Emergency Care Journal 2025 volume 21:13573 If you hear a new worrisome heart murmur... Erika Poggiali,1 Francesco Maria Sacco,2 Giudy Ragonesi2 1Emergency Medicine Unit, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, Milan; 2Cardiology Unit, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, Milan, Italy Question What is the most likely diagnosis? 1. Pulmonary hypertension 2. Acute mitral regurgitation 3. Post-myocardial infarction ventricular septal defect 4. Free wall rupture Answer The right answer is post-myocardial infarction (MI) ventricular septal defect (VSD). Post-MI VSD is the most common type of mechanical complication after acute MI1,2 that occurs in approxi- mately 0.21% with ST-segment elevation MI and in 0.04% with non-ST-segment elevation MI,3 within the first week.4 It is a surgi- cal emergency associated with a high morbidity and mortality rate (80% at 30 days).5 Risk factors are older age, female sex, a history of heart failure, and chronic kidney disease.6 Symptoms may include dyspnea and orthopnea. Clinical examination reveals hypotension, cool peripheries, oliguria, and a new pansystolic mur- mur, with signs of pulmonary venous congestion. A 12-lead ECG may identify ongoing ischemia, evolving myocardial infarction, Q wave, and associated ventricular arrhythmia. A bedside echocar- diogram is done to confirm the diagnosis and evaluate the size and location of a left-to-right shunt, biventricular function, and mitral regurgitation.2 A heart team approach is always recommended: An 86-year-old woman presented to our emergency department for acute dyspnea without chest pain. She had taken amoxicillin/clavu- lanate 1 g/q12h for acute bronchitis. She underwent a left nephrec- tomy for cancer twenty years earlier. Blood pressure, heart rate, peripheral oxygen saturation, respiratory rate, and body tempera- ture were 110/60 mmHg, 112 bpm, 90% with a non-rebreather mask (15 L/min), 25 breaths/min, and 36.5°C, respectively. Arterial blood gas documented pH 7.31, pCO2 29 mmHg, pO2 49 mmHg, SatO2 90%, HCO3 14.6 mEq/L, lactates 3.8 mmol/L. Chest examination revealed absent vesicular murmur in the basal regions, crackles in the upper ones, and a pansystolic murmur. A lung ultra- sound showed a white lung pattern with a severe pleural effusion and non-collapsible inferior vena cava. Laboratory findings docu- mented WBC 18,610/mm3 with CRP 84 mg/L (n.v.<10), AST 489 U/L (n.v. 11-34), ALT 296 U/L (n.v.<33), and troponin T 5191 ng/L (n.v.<20). ECG and echocardiography are reported in Figure 1 and Video 1, respectively. Correspondence: : Erika Poggiali, M.D. Emergency Medicine Unit, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, Via G.B Grassi 74, 20157 Milan, Italy. E-mail: erikapoggiali2@gmail.com Key words: ventricular septal defect; myocardial infarction; cardio- genic shock; complications. Conflict of interest: EP is a member of the editorial board of Emergency Care Journal. The authors declare that they have no com- peting interests, and all authors confirm accuracy. Ethics approval and consent to participate: as this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: the patient provided consent for access to medical records at the time of admission. Availability of data and materials: all data underlying the findings are fully available upon reasonable request to the corresponding author. Received: 1 January 2025. Accepted: 21 January 2025. Early view: 13 February 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:13573 doi:10.4081/ecj.2025.13573 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. optimal timing of surgical treatment should be discussed between a cardiac surgeon, cardiologist, and cardiac intensivist. Medical treatment is ineffective.7 Surgery is the only definitive treatment, but with high operative mortality and morbidity. Intra-aortic bal- loon pumps (IABPs) with pharmacotherapy are used in >80% of emergencies – as in our case – and 65% of urgent repairs.8 Options in patients who are not candidates for VSD repair include percuta- neous closure, mechanical support for heart transplant, and pallia- tive medical therapy.2 References 1. Reddy SG, Roberts WC. Frequency of rupture of the left ven- tricular free wall and ventricular septum among necropsy cases of fatal acute myocardial infarction since introduction of coro- nary care units. Am J Cardiol 1989;63:906-11. 2. Damluji AA, van Diepen S, Katz JN, et al. American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Surgery and Anesthesia; and Council on Cardiovascular and Stroke Nursing. Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association. Circulation 2021;144:e16-e35. 3. David TE. Post-infarction ventricular septal rupture. Ann Cardiothorac Surg 2022;11:261-7. 4. Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricu- lar septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27-32. 5. Shahreyar M, Akinseye O, Nayyar M, et al. Post-Myocardial Infarction Ventricular Septal Defect: A Comprehensive Review. Cardiovasc Revasc Med 2020;21:1444-9. 6. Rogers WJ, Frederick PD, Stoehr E, et al. Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J 2008;156:1026–34. 7. Lemery R, Smith HC, Giuliani ER, et al. Prognosis in rupture of the ventricular septum after acute myocardial infarction and role of early surgical intervention. Am J Cardiol 1992;70:147- 51. 8. Ibanez B, James S, Agewall S, et al. ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119–77. Images in emergency [Emergency Care Journal 2025; 21:13573] [page 13] Figure 1. ECG at admission. Online Supplementary Material Video 1. Echocardiography.