Ventricular Septal Rupture Ventricular septal rupture usually is heralded by a loud sys- tolic murmur and HF or shock, depending on the size of the defect and the degree of RV and LV dysfunction. Data from the GUSTO-1 (The Global Use of Strategies to Open Occluded Coronary Arteries) trial and the SHOCK registry O Gara et al 2013 ACCF/AHA STEMI Guideline e393 indicate that ventricular septal rupture occurs most often within the first 24 hours in patients with STEMI treated with Emergency surgical repair is neces- sary, even in hemodynamically stable patients,479 481 because the rupture site can expand abruptly, resulting in sudden hemo- dynamic collapse in previously stable patients.481 Temporiz- ing medical treatment consists of inotropic and vasodilator agents, with IABP when needed. The surgical mortality rate remains high, especially among patients with shock, ranging Mortality risk is higher for patients with inferior-basal defects than for those with anterior-apical defects. Percutaneous closure is a less invasive option that might allow for initial hemodynamic stabilization, but experience with this approach is limited, and residual shunts are common. Further technical developments and prospective trials are required to identify patients best suited for transcatheter closure. 9.4.4. LV Free-Wall Rupture Free-wall rupture is characterized by recurrent chest pain and ST-T-wave changes, with rapid progression to hemodynamic collapse, electromechanical dissociation, and death.484 It is observed most frequently in patients with first MI, anterior infarction, the elderly, and women. Other risk factors include hypertension during the acute phase of STEMI, lack of ante- cedent angina or prior MI, absence of collateral blood flow, Q waves on ECG, use of corticosteroids or nonsteroidal anti-inflammatory drugs, and administration of fibrinolytic therapy >14 hours after symptom onset.485,486 Pseudoaneu- rysm formation with contained rupture and tamponade can be recognized with transthoracic echocardiography, and emergency surgery should be considered. 