I have no experience.

Yes our department had patient with rupture of ventricular septum following MI and survived once surgically managed. Clinically had loud murmur and thrill.Timing of diagnosis and surgery is pretty important for these kind of patients.

Yes. This is so called AMI-related VSD.  It occurs about 18–24 hours after myocardial infarction and is most commonly associated with anterior myocardial infarction.

http://www.ncbi.nlm.nih.gov/pubmed/19036747

A paper from our institution.

In our experience the results are much better when surgery is delayed.

In patients operated on in emergency the myocardial tissue around the ventricular septal defect are friable and fragile and makes patch closure challenging with frequent early and acute recurrence of the septal defect leading finally to death. Obviously enlargement of the defect to the healthy myocardium is unrealistic.

We use medical management with always Intra aortic counter pulsation, drugs, and when needed mechanical ventilation and/or dialysis.

After two weeks, or even more, surgery can be performed in a stable patient with "solid"myocardial tissue. In such a case the results are equivalent to the results of elective surgery depending of the same risk factors (age, co-morbidities).

Simple spoken, delayed surgery results in better outcomes because the high risk patients die before they get on the table.

The problem is, that we have lacking evidence and knowledge what to do with primary unstable patients in CS with VSD.

I beg to differ that surgery could be delayed in these patients.

Prognosis in rupture of the ventricular septum after acute myocardial infarction and role of early surgical intervention

Robert Lemery, MD,Hugh C. Smith, MD,Emilio R. Giuliani, MD,Bernard J. Gersh, MB, ChB, DPhil

pulblished in The American Journal of Cardiology

Volume 70, Issue 2, 15 July 1992, Pages 147–151

thank you so very much for the answers. but my question was about papillary muscle rupture, septal rupture and free wall rupture at a time. i mistyped my question. anyway thank you all the worthy seniors for their opinion.

May I ask two simple questions to Dr Fuernau?

Do you consider a patient who needs Intra aortic balloon counterpulsation, inotropic support, mechanical ventilation and dialysis as a low risk patient?

Have you some experience and/or some evidence to demonstrate that the group you defined as high-risk patients have better results with immediate surgery?

We did this choice because we had better results but obviously the most severe patients have the worse results.

We define low/high risk by absence or presence of cardiogenic shock, so your patient is obviously high risk. Most of these patients in shock will not survive to day 14, just look on the kaplan meier curves of any study in CS (e.g. in the IABP SHOCK II trial >80 % with negative 30 day outcome died until day 14). Therefore most of the high risk patients will not undergo surgery with a 14 day delay approach and this clearly explains why results seem to be better. You should follow up all patients with VSD from diagnosis and calculate early deaths before surgery also.

In our opinion not only the VSD is outcome relevant, but also the CS itself contributes to mortality.

Randomized controlled trials are lacking and can not be easily performed because this is a rather rare situation. But e.g. this cohort study also recommends early surgery:

http://www.ncbi.nlm.nih.gov/pubmed/19379878

Thank you for your answer. I was in a center with a large experience of this complication, surprisingly the incidence was much higher in the South part of France than in the North.

We did not performed a controlled study but our previous results observed on a group of 50 patients operated on in emergency were so poor that we modified our approach and obtained much better results. Indeed death before surgery was taken into account.It is not very fair to say that our results seems better, because in fact they were better.

Sory. I do not have.

Yes, I had 26 yr ago a successfull experience with one male patient  55 yr of age. He had ruptured septum after AMI in my University of Belgrade Emergency Center CCU. He survived after 4 weeks of intensive care balancing continously  to achieve optimal systemic and pulmonary pressure. After that I transfered him with a helicopter  to the  Card.surgery Dept. of prof. N. Radovanovic in Novi Sad, where he was succesfully operated and went home. He was later my patient in an outclinic.

I've studied postinfarction cardiac rupture limited to free wall of the left ventricle in patients died in CCU. There was a different time from the onset a chest pain that did not respond to opiates and death ( in some individuals up to 12 hours, and in these patients a surgical repair could be conducted with possible survival). I have no personal experience about the survival of patients with multiple heart rupture.

Sorry, I have not personal experience on multiple heart ruptures during AMI but I find the possibility of survival of such patients  as a very doubtful. All of our ruptures occured early, some very early. 

Post MI ventricular septal rupture is generally managed waiting as long as clinically possible to improve the surgical result. The reason is related to the inconsistency of peri-infarcted tissue in the weeks following the acute phase. Post MI papillary rupture is an acute complication due to the massive mitral regurgitation. Post MI free ventricular wall rupture is a generally a final complication with few exception represented by cases with subtile wall fissuration of the necrotic area with thrombus closing the hole. I remember single patients surviving these distinct complications but no one surviving with the three at the same time. A post MI free wall rupture with pericardial tamponade was successfully treated in my Department with surgeons at bed site and immediate starting of cardiac surgery during resuscitation maneuvers.

It has to be a perfect storm. The right time, the right circumstance (so that you can support them) and an experienced surgical team. At the house that Cooley built, we have a wonderful surgical service that is incredibly responsive but the planets must be aligned to be successful. The OR is open. A surgeon is free and the rupture is discovered rapidly. Any breakdown in the chain is failure. When Dr. Cooley first studied their experience with these patients, the mortality was 50% and they decided not to publish. A mistake as these are still the numbers that we live with.

James Wilson, Sir very nice comment. thank you