Abstract
Background
Ventricular septal rupture (VSR) post myocardial infarction (MI) is a rare, high-risk complication requiring urgent intervention. Fusion imaging (FI), integrating echocardiography and fluoroscopy, offers a novel approach for percutaneous closure in unstable patients.
Case Summary
A 60-year-old man developed cardiogenic shock and basal VSR after inferior MI stent placement. Echocardiography confirmed the defect with a left-to-right shunt. Using FI, percutaneous closure with a 16-mm Amplatzer device was completed under real-time guidance. Post-procedure imaging revealed a well-seated device with minimal residual shunt.
Discussion
Overlaying echocardiographic imaging on fluoroscopy enhances procedural precision and can reduce radiation and procedural time. This case represents FI-guided post-MI VSR closure.
Take-Home Messages
FI enables rapid, accurate percutaneous procedures in critically ill patients, minimizing procedural time and risks. We present our experience using FI to reduce crossing attempts and improve device deployment accuracy in a critically ill patient with VSR.
Key words: fusion imaging, myocardial infarction, percutaneous closure, transesophageal echocardiography, ventricular septal rupture
Graphical Abstract
History of Presentation
A 60-year-old man presented to the emergency department from an outside hospital with central chest pain radiating to his left shoulder. An ECG showed the presence of acute inferior myocardial infarction (MI). He subsequently underwent placement of a drug-eluting stent in the right coronary artery; however, his post-procedural course was complicated by the development of a harsh, left parasternal, pansystolic murmur. Subsequent two-dimensional (2D) transthoracic echocardiography revealed a basal ventricular septal rupture (VSR) with a left-to-right shunt. He also developed cardiogenic shock requiring mechanical circulatory support with ventricular unloading using a percutaneous left ventricular device (Impella, Abiomed, Inc.) before being transferred to our institution.
Past Medical History
His past medical history was significant for hypertension, hyperlipidemia, and coronary artery disease. Cardiac catheterization had shown moderate-to-severe stenosis in the mid-circumflex artery and diffuse mild-to-moderate disease in the distal left anterior descending vessel.
Investigations
2D transesophageal echocardiography (TEE) was performed, which showed a 1.7-cm VSR with left-to-right shunting, moderate left ventricle (LV) systolic dysfunction with a LV ejection fraction of 35% to 40%, proximal LV inferior wall aneurysm, poor right ventricle (RV) function, and a large pericardial effusion (Figure 1). Mild mitral and tricuspid regurgitation was also noted.
Figure 1.
Two-Dimensional Transesophageal Echocardiography
Subcostal examination. The arrows point to ventricular septal rupture (VSR) in B mode (left) and using color Doppler flow mapping (right). LV = left ventricle; PE = pericardial effusion; RV = right ventricle.
Management
Based on the patient's critical illness and debility, our multidisciplinary team made the decision to proceed with a percutaneous VSR repair in lieu of an open surgical repair. To improve percutaneous closure, we elected to employ fusion imaging (FI) (EchoNavigator; Philips Healthcare), which required TEE probe intubation and optimal positioning to align live echocardiographic images with fluoroscopy. After obtaining the right femoral access and placing pre-close devices, we then advanced a Judkins catheter (JR4; Cordis) over a supra-core wire to cross the aortic valve into the LV (Figure 2). Next, FI was used to mark the location of the defect on fluoroscopy to guide catheter placement and expedite the crossing of the VSR using the JR4 catheter and the aid of an angled glide wire. Once across, we advanced our JR4 catheter into the RV and exchanged our glide wire for a 0.035-inch supra-core wire before advancing the system into the right pulmonary artery. After the wire exchange, we then externalized our supra-core wire using a snare in right pulmonary artery to create an arteriovenous rail from the right femoral artery to the right internal jugular vein. Following externalization of the wire, we advanced a 10-F Trapezio (Abbott) delivery system and a 16-mm Amplatzer closure device across the VSR into the aorta in antegrade fashion under continued FI guidance (Figure 3). Subsequently, we pulled the delivery system back into the LV before deploying the LV side of the closure device. After confirming adequate contact with the ventricular septum, we then proceeded with deploying the right side of the device under live, concomitant FI guidance. After verifying adequate contact with the VSR site, the closure device was deployed against the ventricular septum (Video 1). The use of FI helped expedite the crossing and deployment of the device without the need for recapture and confirmed adequate device positioning, allowing for a single continuous deployment. After successfully repairing the VSR, we then performed a pericardiocentesis, removing 800 mL of serosanguineous fluid from the pericardial space. The appearance of the fluid and absence of myocardial free wall rupture suggested a reactive or inflammatory effusion, possibly secondary to postinfarction pericarditis.
Figure 2.
Fluoroscopy Image
The black arrow points to the transesophageal ultrasound probe, and the yellow arrow points to the LV unloading device. The white arrow denotes the retrograde guidewire, which is placed in the RV after crossing the aortic valve, the LV, and the ventricular septal rupture site (red arrow). LV = left ventricle; RV = right ventricle.
Figure 3.
Fusion Imaging
Two-dimensional transesophageal echocardiography 4-chamber view is superimposed on the fluoroscopy screen. Ventricular septal rupture (VSR) closure device (D) deployment using the catheter passing through the rupture site is demonstrated. LA = left atrium; LV = left ventricle; RV = right ventricle.
Outcome and Follow-Up
Follow-up 2D transthoracic echocardiography performed the following day showed a well-seated device with a small residual left-to-right shunt and a trivial pericardial effusion (Figure 4). Subsequently, his LV function improved to an LV ejection fraction of 50% to 55%. However, his RV function remained unchanged. The patient remained in the intensive care unit until day 3 post-procedure. The patient remained hemodynamically stable and showed continued improvement in LV function on echocardiography. The next day, he was able to be discharged home in stable condition after Impella weaning.
Figure 4.
Two-Dimensional Transthoracic Echocardiography
The closure device (D) is shown in position. The arrow points to a small residual shunt. LV = left ventricle; RV = right ventricle.
Discussion
VSR is a life-threatening complication that typically develops in 3 to 5 days following an acute MI. Rapid management is paramount in the survival of a critically ill patient, especially in the setting of hemodynamic instability.1, 2, 3 Open cardiac surgery has traditionally been the treatment of choice to close post-MI VSR, but more recently, the less invasive percutaneous approach has been successfully described. In the present case, we used FI technology, which integrates live/real-time TEE images on the fluoroscopic screen.4 A primary advantage of FI guidance in our critically ill patient was the accurate display of the VSR location by 2D TEE, which resulted in a more rapid and time-saving closure device deployment across the VSR without the need for repetitive crossing attempts. Overall, reductions in procedural duration also helped reduce the radiation burden, making the procedure safer for both the patient and the staff involved.4,5 The use of FI guidance can also reduce the risk of complications related to device manipulation, such as myocardial wall injury or perforation. The fusion of TEE and fluoroscopy with the EchoNavigator system was particularly advantageous in this case, complementing the structural insights provided by 2D TEE with enhanced spatial orientation. This integration was especially valuable in our hemodynamically unstable patient, allowing precise localization of the VSR and efficient deployment of the closure device, while minimizing manipulation in the fragile post-infarct septum. Prior literature, including a ventricular septal defect closure case using FI guidance, has demonstrated the utility of FI in structural heart interventions.6 However, to our knowledge, its use in the emergency setting of post-MI VSR closure, where rapid procedural navigation is crucial, has not been thoroughly described. In the literature, FI has been successfully described in the performance of many other complex percutaneous procedures, including mitral valve repair, valvular annuloplasty, paravalvular leak closure, left atrial appendage closure, transcatheter aortic valve replacement, congenital atrial/ventricular septal defect closure, and patent foramen ovale closure.5, 6, 7 Here, we describe the use of FI guidance in assisting the percutaneous closure of a post-MI VSR in a critically ill patient. Despite the successful deployment of the device, a small residual shunt was observed in our patient. This shunt is not unusual after both surgical and percutaneous closures because of the friable nature of the infarcted myocardium and was successfully managed conservatively following device closure.8
Conclusions
We describe the successful use of FI guidance to facilitate rapid percutaneous closure of a post-MI VSR in a critically ill and hemodynamically unstable adult. This case highlights the potential role of FI in enhancing procedural efficiency and safety in emergency structural heart interventions.
Take-Home Messages
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Post–MI VSR is a life-threatening emergency that may require percutaneous closure.
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FI integrates real-time echocardiography and fluoroscopy to enhance procedural precision.
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FI allowed rapid, accurate device placement with reduced procedural time and complications in this critically ill patient.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors acknowledge the help of our other contributing fellows within the department.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For a supplemental video, please see the online version of this paper.
Appendix
Fusion Imaging Utilization
Transesophageal echocardiography 4-chamber view is integrated and superimposed on the fluoroscopy screen. Deployment of the closure device (D) on the left side and then the right side of the ventricular septum is demonstrated. A single frame with labels is displayed at the beginning of the video. LA = left atrium; LV = left ventricle; RV = right ventricle.
References
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Associated Data
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Supplementary Materials
Fusion Imaging Utilization
Transesophageal echocardiography 4-chamber view is integrated and superimposed on the fluoroscopy screen. Deployment of the closure device (D) on the left side and then the right side of the ventricular septum is demonstrated. A single frame with labels is displayed at the beginning of the video. LA = left atrium; LV = left ventricle; RV = right ventricle.