Silent post-infarction ventricular septal rupture obscured by apical thrombus formation: A case report.

Ventricular septal rupture (VSR) is a catastrophic mechanical complication of acute myocardial infarction, usually associated with hemodynamic collapse and high mortality. We report an extremely rare case of delayed post-infarction VSR that remained hemodynamically stable without surgical intervention. A 53-year-old male smoker presented with persistent chest pressure for three days and was diagnosed with anterior myocardial infarction. Coronary angiography revealed multivessel coronary artery disease. Although the patient remained clinically stable, transthoracic echocardiography on day 11 demonstrated a large apical thrombus without evidence of VSR. After anticoagulation therapy, the thrombus resolved, and an apical VSR became apparent on day 36. Despite moderate left-to-right shunting, right ventricular pressure and cardiac output were preserved, and neither heart failure nor cardiogenic shock developed. Cardiopulmonary exercise testing before discharge confirmed preserved exercise tolerance. Long-term follow-up demonstrated improvement in left ventricular function and a reduction in shunt volume. Temporary sealing of the septal defect by an apical thrombus may have prevented acute hemodynamic deterioration. This case suggests that conservative management with comprehensive hemodynamic and functional assessment may lead to favorable outcomes in carefully selected patients with preserved hemodynamics. Learning objective: Ventricular septal rupture (VSR) and apical thrombus are relatively rare complications of acute myocardial infarction. Although short-term mortality following VSR remains high, conservative management may be feasible in selected cases. In the present case, VSR was identified after treatment of an apical thrombus. The presence of the apical thrombus might have contributed to maintaining hemodynamic stability during the acute phase of VSR.