부산대학교 도서관

A 70-year-old man visited emergency department due to chest pain for 2 hours` duration. Electrocardiogram (ECG) showed normal sinus rhythm with ST elevation as well as Q wave in leads II, III, and aVF. Soon afterward, ECG showed ventricular fibrillation. Cardioversion was performed, the patient`s cardiac rhythm returned to normal sinus rhythm. But, the patient went into shock and in drowsy mental status. His blood pressure was checked 80/60 mmHg. Heart sounds were regular, and cardiac murmurs were not audible. Cardiac troponin I level was 0.35 ng/mL (reference range<0.4 ng/dL). Acute right coronary artery (RCA) territory myocardial infarction was suspected, we planned percutaneous coronary intervention (PCI). However, because of the patient`s age, drowsy mentality, his family declined coronary intervention. One day later, his condition improved dramatically without specific treatment or intervention. His mental state became clear, and vital signs were stabilized. However in contrast to the previous examination, grade 3 pansystolic murmur was checked at the left sternal border. Echocardiogram revealed right ventricle (RV) hypokinesia, 1.7 cm sized ventricular septal defect (VSD) with continuous shunt flow. Seven days later, PCI at RCA was done. Twenty five days later, VSD closure surgery was done. One hour after surgery, he went to shock, central venous pressure was elevated. But, cardiac output decreased to 2.4 L/min by non invasive cardiac output monitor. And echocardiogram revealed that there was no shunt flow, pericardial effusion, or significant valvular dysfunction. However, RV dysfunction and inferior vena cava plethora were observed. Unfortunately, the patient did not recover from shock and died. We made the careful assumption that acute myocardial infarction caused RV infarction and dysfunction, which led to cardiogenic shock during the initial hospital visit. VSD occurred in this patient after 2 days of medical treatment without intervention. The left ventricle might have functioned as a right ventricular assist device (RVAD). However, after closure of the VSR, the RVAD function of the left ventricle disappeared and the patient died from decompensated RV failure.