**Introduction/Hypothesis:**
Introduction: Ventricular septal rupture (VSR) is a devastating complicating following acute myocardiac infarction and is often complicated by cardiogenic shock with high in-hospital mortality.

**Methods**
Case: A 73-year-old woman developed left-sided chest and back pain 10 days prior to presentation to the emergency department with shortness of breath. Comorbidities notable for type 2 diabetes mellitus, chronic kidney disease stage II, and hypertension. On arrival, patient was tachycardic but otherwise vitally stable. Physical exam was notable for a new 3/6 holosystolic and 2+ pitting edema bilaterally. Electrocardiogram (EKG) showed ST segment elevation in the anterior lateral and inferior leads and initial troponin was elevated.  Patient was loaded with aspirin and heparin and transferred to hospital with a cardiac catheterization laboratory.
There, patient underwent a transthoracic echocardiogram (TTE) which demonstrated a ventricular septal defect with a left to right shunt and decreased ejection fraction of 34%. The right ventricle was also noted to be enlarged with a mildly reduced systolic function and RVSP of 56 mm Hg (Figure 1). VSR was again appreciated on computed tomography cardiac angiogram (Figure 2). 
A subsequent coronary angiography revealed 90% occlusion of the mid-left anterior descending (LAD) with TIMI 2 flow (Figure 3).  Revascularization was not attempted. A right heart catheterization demonstrated Qp/Qs ratio of 2.5, cardiac index of 1.5 L/minute/m2, pulmonary capillary wedge pressure of 24 mm Hg, and mean right atrial pressure of 16 mm Hg.  An intra-aortic balloon pump (IABP) was placed during procedure to optimize hemodynamics. 
Patient was aggressively diuresed in the CCU with improvement in symptoms and hemodynamics.  Cardiovascular surgery were consulted and elected for operative closure of the VSR but gave time for scar formation prior to repair.
After 34 days in the hospital, patient underwent successful operative ventricular septal defect closure. She did well postoperatively and was subsequently transferred to the inpatient rehabilitation service and later dismissed to home with family support.

**Results**
Decision Making: This patient was diagnosed with post-myocardial infarction VSR complicated by cardiogenic shock (CS) and multiorgan failure requiring hemodynamic support with IABP.  The ideal timing of surgical intervention for post-myocardial infarction VSR with cardiogenic shock remains controversial as there is high mortality when surgery is performed acutely compared to delayed intervention. In this case, patient was able to undergo successful IABP placement to maintain hemodynamic stability and allow for delayed surgery.

**Conclusion**
Conclusion: We present a case of post myocardial infarction VSR complicated by cardiogenic shock. Patient underwent IABP placement with improvement in hemodynamic stability and subsequent bridge to delayed repair.



**Introduction/Hypothesis:**
**Introduction:** Ventricular septal rupture (VSR) is a devastating complicating following acute myocardiac infarction and is often complicated by cardiogenic shock with high in-hospital mortality.

**Methods**
**Case:** A 73-year-old woman developed left-sided chest and back pain 10 days prior to presentation to the emergency department with shortness of breath. Comorbidities notable for type 2 diabetes mellitus, chronic kidney disease stage II, and hypertension. On arrival, patient was tachycardic but otherwise vitally stable. Physical exam was notable for a new 3/6 holosystolic and 2+ pitting edema bilaterally. Electrocardiogram (EKG) showed ST segment elevation in the anterior lateral and inferior leads and initial troponin was elevated.  Patient was loaded with aspirin and heparin and transferred to hospital with a cardiac catheterization laboratory.
There, patient underwent a transthoracic echocardiogram (TTE) which demonstrated a ventricular septal defect with a left to right shunt and decreased ejection fraction of 34%. The right ventricle was also noted to be enlarged with a mildly reduced systolic function and RVSP of 56 mm Hg (Figure 1). VSR was again appreciated on computed tomography cardiac angiogram (Figure 2). 
A subsequent coronary angiography revealed 90% occlusion of the mid-left anterior descending (LAD) with TIMI 2 flow (Figure 3).  Revascularization was not attempted. A right heart catheterization demonstrated Qp/Qs ratio of 2.5, cardiac index of 1.5 L/minute/m2, pulmonary capillary wedge pressure of 24 mm Hg, and mean right atrial pressure of 16 mm Hg.  An intra-aortic balloon pump (IABP) was placed during procedure to optimize hemodynamics. 
Patient was aggressively diuresed in the CCU with improvement in symptoms and hemodynamics.  Cardiovascular surgery were consulted and elected for operative closure of the VSR but gave time for scar formation prior to repair.
After 34 days in the hospital, patient underwent successful operative ventricular septal defect closure. She did well postoperatively and was subsequently transferred to the inpatient rehabilitation service and later dismissed to home with family support.

**Results**
**Decision Making:** This patient was diagnosed with post-myocardial infarction VSR complicated by cardiogenic shock (CS) and multiorgan failure requiring hemodynamic support with IABP.  The ideal timing of surgical intervention for post-myocardial infarction VSR with cardiogenic shock remains controversial as there is high mortality when surgery is performed acutely compared to delayed intervention. In this case, patient was able to undergo successful IABP placement to maintain hemodynamic stability and allow for delayed surgery.

**Conclusion**
**Conclusion**: We present a case of post myocardial infarction VSR complicated by cardiogenic shock. Patient underwent IABP placement with improvement in hemodynamic stability and subsequent bridge to delayed repair.



Post-Myocardial Infarction Ventricular Septal Rupture complicated by Cardiogenic Shock: Successful Intraaortic Balloon Pump Bridge to Delayed Surgical Repair 

This course will explore basic and cutting-edge imaging techniques to improve patient care and hone individual skills in performance and interpretation of echocardiography, nuclear cardiology, cardiac computed tomography, and cardiovascular magnetic resonance imaging. Days will reinforce how cardiovascular imaging may improve comprehension in ischemic heart disease, structural heart disease, cardiomyopathies, and heart failure. Experts will utilize novel techniques to reinforce key topics including taped interventional cases and a strong emphasis on case presentations.