A 82-year-old man with a past medical history of gastroesophageal reflux with Barrett’s esophagus, hypertension, and dyslipidemia presented with an acute ischemic ventricular septal defect (VSD). He presented to a peripheral hospital with ST-elevation myocardial infarction (STEMI) of the anteroseptal territory and was treated with intravenous thrombolytics. He had persistent chest pain and was transferred to our hospital where coronary angiography revealed recanalization of the culprit lesion in the left anterior descending artery but with residual stenosis. A decision was made to treat with a drug eluting stent. Urgent transthoracic echocardiography demonstrated a large VSD with an enlarging left-to-right shunt. His left ventricular ejection fraction was estimated at 45–50% with reasonable right ventricular function. Serial laboratory investigations revealed rising lactate and serum creatinine, and he had become anuric. We discussed with the patient the high-risk nature of potential intervention and presented the options of ongoing medical therapy alone, extracorporeal membrane oxygenation, and definitive repair. He wished to proceed with emergent repair of the post-myocardial infarction VSD
