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A 65 year old woman was transferred to our hospital eight days after sustaining an inferior myocardial infarction. She had undergone thrombolysis and was discharged after an uneventful early course of recovery. She was readmitted two days later in cardiac failure, with a new systolic murmur. Two dimensional echocardiography in our unit demonstrated a large defect in the basal muscular ventricular septum with an aneurysmal portion of intact tissue bulging into the right ventricle. Colour Doppler examination showed left-to-right flow through the defect, reaching the right ventricle via an opening in the basal end of the aneurysm. The right ventricle was dilated and there was a moderate pericardial effusion. The patient was brought to theatre where it was found that virtually the whole of the ventricular septum had infarcted. Multiple attempts were made to repair the defect, but the necrotic nature of the surrounding tissue made adequate repair impossible. The patient died shortly after the operation.
The microarchitecture of the septum, with a laminar arrangement of myocytes and connective tissue, leads to the existence of possible cleavage planes. Conditions of infarction combined with the hydrostatic pressure of the left ventricle can cause splits within the wall, giving rise to the unusual appearances seen here.
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