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J Clin Ultrasound 2019 Jan 4. Epub 2019 Jan 4.

Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, China.

Right ventricular (RV) wall dissection following ventricular septal rupture related to inferior myocardial infarction (MI) is an extremely rare complication with a high mortality rate. We report the case of a 61-year-old man who was admitted to our hospital because of syncope and intermittent chest pain with a precordial murmur. Transthoracic echocardiography showed a rupture at the basal infero-posterior septum and RV free-wall dissection forming an echolucent cavity that extended beyond the septum and subsequently re-entered into RV chamber. Read More

Asian Cardiovasc Thorac Ann 2018 Nov 1;26(9):697-700. Epub 2017 Feb 1.

Department of Cardiovascular Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.

A 67-year-old man presented with late left ventricular free wall rupture 1 month after an extended sandwich technique through a right ventricular incision for ventricular septal rupture following an inferoposterior acute myocardial infarction. We found that residual infarcted myocardium had led to left ventricular aneurysm formation. A pericardial patch on the left ventricular side at the initial operation should have been secured further from the septal defect using a larger needle. Read More

Echocardiography 2017 Nov 30;34(11):1680-1686. Epub 2017 Oct 30.

Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two-dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two-dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. Read More

Indian Heart J 2017 Sep - Oct;69(5):628-633. Epub 2017 Apr 1.

Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India. Electronic address:

Objectives: Ventricular septal rupture (VSR) is a rare but feared complication after myocardial infarction (MI). The objective of this study was to investigate the effects of thrombolytic therapy on the patterns of VSR following MI.

Methods: 30 consecutive patients admitted to a single tertiary level cardiac hospital with a diagnosis of acute MI and developed VSR in the hospital were included. Read More

BMJ Case Rep 2017 Oct 13;2017. Epub 2017 Oct 13.

Cardiology, Tokyo Teishin Hospital, Tokyo, Japan.

We report on an 84-year-old woman with anteroseptal acute myocardial infarction. Emergency coronary angiography revealed the occlusion of proximal left anterior descending artery without collateral circulation, and percutaneous coronary intervention was performed. Two drug eluting stents were implanted, and the procedure was concluded with thrombolysis in myocardial infarction grade 3 without complications. Read More

Intern Med 2017 Sep 21;56(18):2435-2439. Epub 2017 Aug 21.

Department of Cardiology, Ogaki Municipal Hospital, Japan.

Although improved treatments for acute myocardial infarction (AMI) have considerably reduced the mortality of AMI in the past two decades, the treatment for ventricular septal rupture (VSR)-a rare but life-threatening mechanical complication of AMI-still remains quite challenging. We herein describe the case of a high-surgical-risk patient with VSR after AMI who was successfully treated using tolvaptan (a novel V-receptor antagonist) without any mechanical support. Read More

Korean J Thorac Cardiovasc Surg 2017 Jun 5;50(3):211-214. Epub 2017 Jun 5.

Department of Cardiothoracic Surgery, Hanllym University Sacred Heart Hospital, Hanllym University College of Medicine.

Outcomes of ventricular septal rupture (VSR) as a complication of acute myocardial infarction are extremely poor, with an in-hospital mortality rate of 45% in surgically treated patients and 90% in patients managed with medication. Delaying surgery for VSR is a strategy for reducing mortality. However, hemodynamic instability is the main problem with this strategy. Read More

J Invasive Cardiol 2017 May;29(5):E60

University of Oxford, Department of Cardiology, John Radcliffe Hospital, Headley Way, Oxford, Oxfordshire OX39DU, United Kingdom.

A 70-year-old man presented with prolonged cardiac chest pain and was awaiting coronary artery bypass surgery following angiography showing extensive multivessel disease. Following further chest pain, cardiac magnetic resonance imaging showed extensive, contained, ventricular rupture, which was managed aggressively with combined bypass surgery and rupture repair. Read More

Medicine (Baltimore) 2017 Mar;96(10):e6191

aDepartment of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. China bThe Pauley Heart Center, Virginal Commonwealth University School of Medicine, Richmond, VA, USA.

Dissection of the interventricular septum (IVS) is an extremely rare entity. An institutional echocardiographic database was retrospectively reviewed; 13 patients with a diagnosis of IVS dissection were found and confirmed by cardiac surgery. The purposes of the study were: to determine the value of transthoracic echocardiography (TTE) in establishing the diagnosis of IVS dissection, and to detail the TTE features of IVS dissection. Read More

Surg Case Rep 2016 Dec 30;2(1):85. Epub 2016 Aug 30.

Department of Cardiovascular Surgery, Kinan Hospital, Shinjo-cho 46-70, Tanabe, 646-8588, Wakayama, Japan.

Background: Ventricular septal rupture (VSR) is a life-threatening complication following acute transmural myocardial infarction. Posteriorly located ruptures are one of the main predictors of poor prognoses because of the surgical difficulties associated with this location.

Case Presentation: A 72-year-old man with a posterior VSR underwent surgical repair via the right atrial approach. Read More

Methodist Debakey Cardiovasc J 2016 Apr-Jun;12(2):122

Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas.

Perfusion 2016 Jul 8. Epub 2016 Jul 8.

Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.

Blood transfusions could have serious consequences for patients. A reduction in the transfusion rate could be accomplished by an optimized blood management. Clear guidelines and awareness among all employees at a single institution have resulted in a reduction in transfusion rates in recent years. Read More

Indian Heart J 2015 Dec 10;67 Suppl 3:S21-3. Epub 2015 Sep 10.

Professor and Head, Department of Cardiology Government Medical College, Kozhikode, Kerala, India.

A previously asymptomatic 53-year-old male presented 5 days after an acute anterior wall myocardial infarction, who was fibrinolytic naïve, with worsening dyspnea. Transthoracic echocardiographic evaluation revealed rupture of the interventricular septum and pseudoaneurysm of the left ventricle, confirmed by angiography. Coronary angiogram revealed multivessel disease. Read More

Echocardiography 2016 Jul 19;33(7):962-9. Epub 2016 Feb 19.

Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.

Objectives: Intramyocardial dissecting hematoma (IDH) after acute myocardial infarction (MI) is a rare form of subacute cardiac rupture and hence management uncertainties. The objective of this study was to describe the clinical course of a small series of IDH patients and to review the available evidence for managing similar cases.

Methods: Eight IDH patients from our center had echocardiographic, coronary angiographic and clinical outcome data reviewed. Read More

Gen Thorac Cardiovasc Surg 2016 Mar 18;64(3):121-30. Epub 2016 Jan 18.

Shiga University of Medical Science, Otsu, Japan.

Postinfarction ventricular septal rupture (VSR) is a lethal structural complication following acute myocardial infarction (AMI). Surgical repair of VSR was first reported in 1957 by Cooley. Since then, many methods have been introduced, variously using right and/or left ventriculotomy. Read More

Int J Cardiol 2016 Mar 14;206:27-36. Epub 2015 Dec 14.

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Canada. Electronic address:

Background: Rupture of the ventricular septum following acute myocardial infarction (AMI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is the only definitive treatment for this condition.

Methods: We review our experience of surgical repair of post-infarction ventricular septal defects (VSDs), analyze the associated risk factors and outcomes, and do a complete review of the literature. Read More

Rev Port Cardiol 2016 Jan 31;35(1):63.e1-5. Epub 2015 Dec 31.

Department of Cardiology, Ramón y Cajal University Hospital, Madrid, Spain.

Ventricular wall rupture has become an infrequent complication of myocardial infarction due to widespread use of prompt reperfusion strategies. Patients suffering myocardial infarction with normal coronary arteries seldom develop severe mechanical complications. We present the case of a patient who developed a ventricular septal rupture following an anteroseptal myocardial infarction and who presented normal coronary arteries at the time of coronary angiography. Read More

J Card Surg 2016 Feb 9;31(2):89-95. Epub 2015 Dec 9.

Department of Cardiovascular Sciences, Catholic University of The Sacred Heart, Agostino Gemelli Policlinic, Rome, Italy.

Background: Takotsubo cardiomyopathy syndrome, commonly occurring in postmenopausal women, is characterized by transient apical systolic dysfunction in absence of coronary lesions. The cardiomyopathy is often observed after intense stressful events such as a major surgical procedure.

Methods: A 72-year-old woman symptomatic for dyspnea at rest, chest pain, and peripheral edema successfully underwent surgery for noncoronary sinus aneurysm-right atrium fistula repair. Read More

Vojnosanit Pregl 2015 Jan;72(1):68-71

Introduction: Acquired ventricular septal defect (VSD) is uncommon, but serious mechanical complication of acute myocardial infarction with poor outcome and high mortality rate in surgically or medically treated patients.

Case Report: We report a 58-year-old male patient admitted to our hospital six days following acute inferior myocardial infarction complicated by ventricular septal rupture with signs of heart failure. Coronary angiography revealed 3-vessel disease, with proximally occluded dominant right coronary artery. Read More

Circ J 2015 2;79(9):2072-4. Epub 2015 Jun 2.

Division of Cardiology, Department of First Internal Medicine, National Defense Medical College.

Int J Cardiol 2015 Apr 17;185:328-32. Epub 2015 Mar 17.

Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China.

Background: Ventricular septal rupture (VSR) following myocardial infarction is a rare complication with high mortality. Although transcatheter closure has emerged as a less invasive method of VSR closure, the optimal timing and technique remain unclear.

Methods: This is a single-center, retrospective, cohort study. Read More

Pan Afr Med J 2014 24;19:68. Epub 2014 Sep 24.

Service de Chirurgie Cardiovasculaire, CHU Ibn Rochd, Casablanca, Maroc.

J Cardiothorac Surg 2015 Jan 21;10. Epub 2015 Jan 21.

Department of cardiology, CHU-Nancy, F-54000, France.

Postinfarction ventricular septal defect (PIVSD) is a devastating mechanical complication following acute myocardial infarction. The management of this pathology is quite challenging, especially in case of complicated cardiogenic shock. The difficulties lie in the timing and type of intervention. Read More

J Clin Ultrasound 2015 Oct 8;43(8):512-5. Epub 2014 Sep 8.

Ultrasound Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.

A 76-year-old man under stable hemodynamic condition was admitted to our hospital for delayed percutaneous coronary intervention following a diagnosis of acute inferior myocardial infarction. Bedside echocardiography revealed ventricular septal rupture at the basal posteroinferior wall with a large left-to-right shunt. Right ventricular free-wall intramyocardial dissection and tricuspid chordae rupture were noted. Read More

J Interv Cardiol 2014 Oct 25;27(5):509-15. Epub 2014 Aug 25.

Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark.

Objectives: We report the long-term all-cause mortality and procedure-related complication rate following transcatheter closure of postinfarction ventricular septal rupture (VSR) in a single tertiary center.

Background: VSR is an exceedingly serious and deathly complication to myocardial infarction. Surgical closure has previously been the treatment of choice, but in the last decade a transcatheter approach has gained ground. Read More

Interact Cardiovasc Thorac Surg 2014 Sep 29;19(3):526-8. Epub 2014 May 29.

Department of Cardiac Surgery, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK

Coronary artery disease in the donor heart is an established cause of early graft failure. However, identification of this before implantation is difficult. Cardiogenic shock associated with significant myocardial infarction during the early postoperative period is rare. Read More

Chin Med J (Engl) 2013 Nov;126(21):4105-8

Coronary Heart Disease Center, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China.

Background: Ventricular septal rupture (VSR) remains an infrequent but devastating complication of acute myocardial infarction (AMI). The best time to undergo surgical repair is controversial and there is currently no risk stratification for patients with VSR to guide treatment. The purpose of this study was to review the clinical outcomes of 70 patients with VSR, to analyze the short-term prognosis factors of VSR following AMI, and to make a risk stratification for patients with VSR. Read More

Cardiol Clin 2013 Nov 13;31(4):519-31, vii-viii. Epub 2013 Aug 13.

Department of Cardiothoracic Surgery, Papworth Hospital, University of Cambridge, Cambridge CB23 3RE, UK.

Acute myocardial infarction (AMI) can result in ischemic, mechanical, arrhythmic, embolic, or inflammatory complications. The development of mechanical complications following AMI is associated with a significantly reduced short-term and long-term survival. Since the introduction of primary percutaneous coronary intervention as the principal reperfusion strategy following acute ST-elevation myocardial infarction, the incidence of mechanical complications, including rupture of the left ventricular free wall, papillary muscle, and ventricular septum, has reduced significantly to less than 1%. Read More

Eur Heart J Acute Cardiovasc Care 2013 Mar;2(1):68-71

The James Cook University Hospital, Middlesbrough, UK.

Dynamic left ventricular outflow tract obstruction is a rare but important complication of myocardial infarction. It occurs acutely and may mimic the presentation of papillary muscle rupture or acquired ventricular septal defect. Unlike these mechanical complications, it does not require circulatory support or cardiac surgical intervention. Read More

Medicina (Kaunas) 2013 ;49(4):200-5

Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.

Ventricular septal defect after myocardial infarction is a rare but often life-threatening mechanical complication. The keys of management are a prompt diagnosis of ventricular septal defect and an aggressive approach to stabilize patient's hemodynamics. Invasive monitoring, judicious use of inotropes and vasodilators, and an intra-aortic balloon pump are recommended for the optimal support of patient's hemodynamics. Read More

Zhonghua Xin Xue Guan Bing Za Zhi 2013 Mar;41(3):195-8

Coronary Heart Disease Center, Cardiovascular Institute and Fuwai Hospital, China Academy Medical Science and Peking Union Medical College, Beijing 100037, China.

Objective: To analyze the short-term prognosis and risk factors of ventricular septal rupture (VSR) following acute myocardial infarction (AMI).

Methods: A total of 70 consecutive VSR patients following AMI hospitalized in our hospital from January 2002 to October 2010 were enrolled in this study. We compared the clinical characteristics of patients with VSR who survived ≤ 30 days (n = 39) and survived > 30 days (n = 31) post AMI. Read More

J Pak Med Assoc 2012 Aug;62(8):861-5

Department of Surgery, Aga Khan University, Karachi.

Objective: To outline the outcome and management of patients with acute myocardial infarction presenting with mechanical complications such as post-infarction ventricular septal defect, mitral regurgitation and left ventricular rupture.

Methods: The retrospective study, conducted in September and October, 2010 at the Aga Khan University Hospital, Karachi, included cases from January 1990 to December 2009. Only 18 cases were found who had presented with such complications. Read More

Heart Surg Forum 2013 Jun;16(3):E150-1

Department of Cardiopulmonary Transplantation and the Center for Cardiac Support, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas, USA.

We describe the case of a 54-year-old woman with a postinfarction ventricular septal defect (VSD) and ventricular free wall rupture who was stabilized with a percutaneous ventricular assist device (pVAD) to allow for myocardial infarct stabilization. Following the rupture of the right ventricular free wall and cardiopulmonary arrest on hospital day 10, pVAD support was promptly converted to extracorporeal membrane oxygenation (ECMO) support for stabilization. After surgical repair was completed, pVAD support was continued for 4 days to allow recovery. Read More

World J Cardiol 2013 May;5(5):151-3

Tobias Gassenmaier, Meinrad Beer, Department of Radiology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany.

A 74-year-old man was admitted to the cardiac catheterization laboratory with acute myocardial infarction. After successful angioplasty and stent implantation into the right coronary artery, he developed cardiogenic shock the following day. Echocardiography showed ventricular septal rupture. Read More

J Cardiothorac Surg 2013 Mar 9;8:44. Epub 2013 Mar 9.

Department of Cardiothoracic Surgery National Heart Centre, Mistri Wing 17 Third Hospital Avenue, Singapore 168752, Singapore.

Background: To review the experience of surgical repair of post-infarction ventricular septal rupture (VSR) and analyze the associated outcomes and prognostic factors.

Methods: Following approval from the Singhealth Centralised Institutional Review Board (reference: 2011/881/C), a retrospective review was performed on 38 consecutive patients who had undergone surgical repair of post-infarction VSR between 1999 and 2011. Continuous variables were expressed as either mean ± standard deviation or median with 25th and 75th percentiles. Read More

J Card Surg 2013 May 3;28(3):273. Epub 2013 Mar 3.

Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan.

J Card Surg 2013 Mar 28;28(2):193-5. Epub 2013 Jan 28.

Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.

Rupture of the ventricular septum occurs in 1% to 2% of all acute myocardial infarctions (MI) requiring surgical intervention in the majority of cases. Furthermore, patch dehiscence and residual shunt are major problems following repair in the acute stage. A delay in repair may prevent patch dehiscence. Read More

BMC Res Notes 2012 Oct 25;5:583. Epub 2012 Oct 25.

Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada.

Background: Ventricular septal rupture (VSR), a mechanical complication following an acute myocardial infarction (MI), is thought to result from coagulation necrosis due to lack of collateral reperfusion. Although the gold standard test to confirm left-to-right shunting between ventricular cavities remains invasive ventriculography, two-dimensional transthoracic echocardiography (TTE) with color flow Doppler and cardiac MRI (CMR) are reliable tests for the non-invasive diagnosis of VSR.

Case Presentation: A 62-year-old Caucasian female presented with a late case of a VSR post inferior MI diagnosed by multimodality cardiac imaging including TTE, CMR and ventriculography. Read More

J Cardiovasc Med (Hagerstown) 2014 Jan;15(1):82-4

UO Cardiologia, Maria Cecilia Hospital - GVM Care & Research, Via Corriera 1, Cotignola, Italy.

Ventricular septal rupture is a rare complication of acute myocardial infarction and its diagnosis can be really challenging especially in the case of complex lesions. Echocardiography is the technique of choice for the detection of mechanical complications following myocardial infarction. The introduction of three-dimensional echocardiography offers new imaging possibilities with precise localization and easiest definition of the defect anatomy. Read More

J Card Surg 2012 Sep 13;27(5):576-80. Epub 2012 Aug 13.

Division of Cardiovascular Medicine, University of Louisville of School of Medicine, Louisville, Kentucky 40202, USA.

Ventricular septal rupture (VSR) complicates acute myocardial infarction (AMI) in less than 0.2% of cases and is usually surgically managed by endocardial patch repair with infarct exclusion. Although successful in 80% of cases, failure of patch repair (often because of patch dehiscence) results in attempts at percutaneous closure as reoperative mortality can be as high as 40%. Read More

Asian Cardiovasc Thorac Ann 2012 Aug;20(4):404-8

Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge CB23 3RE, UK.

Objectives: We reviewed our results and experience over a 14-year period to identify predictors of outcome following surgical repair of postinfarction ventricular septal rupture.

Methods: A retrospective review was carried over a 14-year period. All patients had surgical repair of a postinfarction ventricular septal rupture. Read More

Gen Thorac Cardiovasc Surg 2012 Aug 12;60(8):475-9. Epub 2012 Jun 12.

Department of Cardiovascular Surgery, Japanese Red Cross Nagoya First Hospital, 3-35 Michishita-cho, Nakamura, Nagoya, Japan.

Objectives: Surgical results for post-infarction ventricular septal rupture (VSR) remain poor, even today. The aim of this study was the establishment and clinical evaluation of a simple, standardized septal patch technique for this disease.

Methods: From 1999 to 2011, 16 consecutive patients with a mean age of 73. Read More

Catheter Cardiovasc Interv 2012 Oct 17;80(4):687-99. Epub 2012 Apr 17.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.

Cardiac and aortic pseudoaneurysms are rare complications following myocardial infarction or cardiac surgery. They are characterized by a contained cardiac or aortic rupture within surrounding tissue and have a high mortality rate if left untreated. Percutaneous treatment of cardiac pseudoaneurysms might be a feasible treatment option in patients who are at high risk of reoperative surgery. Read More

Eur Heart J Acute Cardiovasc Care 2012 Apr;1(1):57-9

Hospital de Santa Maria, Lisbon, Portugal.

Ventricular septal rupture (VSR) is nowadays a rare complication of myocardial infarction (MI), but with a mortality rate still very high. Urgent surgical correction is recommended, although in specific cases percutaneous closure of a post-infarct VSR is a therapeutic option or a bridge to surgical correction. We report a case of an 80-year-old woman, with a subacute anterior MI with an antero-septal VSR. Read More

Can J Cardiol 2011 Nov-Dec;27(6):868.e5-7

Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Cardiac rupture represents a catastrophic complication of myocardial infarction with an exceedingly high mortality rate. In rare instances, a myocardial infarction can be complicated by 2 separate forms of rupture. The most common form of ventricular double rupture consists of free wall rupture in association with ventricular septal rupture. Read More

J Intensive Care Med 2013 May-Jun;28(3):151-65. Epub 2011 Jul 11.

University of California, San Francisco, CA 94143, USA.

Cardiogenic shock is often a devastating consequence of acute myocardial infarction (MI) and portends to significant mortality and morbidity. Despite improvements in expediting the time to treatment and enhancements in available medical therapy and reperfusion techniques, cardiogenic shock remains the most common cause of mortality following MI. Post-MI cardiogenic shock most commonly occurs as a consequence of severe left ventricular dysfunction. Read More

Rev Med Suisse 2011 Jun;7(297):1189-92

Service de cardiologie, Département de médecine interne, HUG, 121 I Genève 14.

Despite a marked reduction in mortality after myocardial infarction during the last decades thanks to heart monitoring and early reperfusion, there remains a significant rate of in-hospital mortality. This is a consequence of refractory ventricular dysfunction in most cases, or mechanical complications of myocardial infarction in the remaining cases. Mechanical complications include septal rupture with ventricular septal defect, tamponnade following rupture of the left ventricular free wall, and acute mitral regurgitation due to papillary muscle infarction and rupture. Read More

Acta Cardiol 2011 Apr;66(2):225-30

Department of Cardiology, National Heart Centre, Singapore.

Objective: Ventricular septal rupture (VSR) is a complication of acute myocardial infarction (AMI) that is associated with significant mortality. We aim to review the clinical outcome in the current era.

Methods And Results: Patients admitted to a single tertiary centre from 1997 to 2008 with VSR post-AMI were identified from the local cardiac registry. Read More

Korean J Pediatr 2011 Feb 28;54(2):86-9. Epub 2011 Feb 28.

Division of Pediatric Cardiology, Cardiovascular Center, Yonsei University College of Medicine, Seoul, Korea.

Traumatic ventricular septal defect (VSD) resulting from blunt chest injury is a very rare event. The mechanisms of traumatic VSD have been of little concern to dateuntil now, but two dominant theories have been described. In one, the rupture occurs due to acute compression of the heart; in the other, it is due to myocardial infarction of the septum. Read More