Question
A 62-year-old man presents on post-MI day 4 with acute dyspnea and hypotension. Exam reveals a new 4/6 holosystolic murmur at the left lower sternal border with a thrill. Pulmonary artery catheterization shows a step-up in oxygen saturation from the right atrium (60%) to the right ventricle (83%). What is the diagnosis and definitive management?
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Diagnosis: Acute Post-MI Ventricular Septal Rupture (VSR). Definitive Management: Immediate emergent surgical repair. Clinical Rationale: The key diagnostic clue is the oxygen saturation step-up from the RA to the RV (from 60% to 83%), indicating a left-to-right shunt across the inter-ventricular septum. Papillary muscle rupture (causing acute Mitral Regurgitation) also causes a holosystolic murmur, but the murmur radiates to the axilla, lacks a thrill, and shows no oxygen saturation step-up in the RV. While an Intra-Aortic Balloon Pump (IABP) or temporary mechanical circulatory support can stabilize hemodynamics, emergent surgical intervention is the only definitive treatment.
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