A 51‐year‐old woman with no history of heart disease presented to the emergency room complaining of chest pain of 48 h duration and sudden onset of severe dyspnoea. The blood pressure was 92/60 mm Hg and heart rate was 105 beats per minute. Auscultation showed bilateral inspiratory rales and a grade 3/6 harsh, holosystolic murmur along the left sternal border. An ECG showed ST‐segment elevation in leads V2–V5. Real‐time three‐dimensional (RT3‐D) transthoracic echocardiography disclosed a 16 mm diameter through‐and‐through infarct ventricular septal defect (VSD; panels A, B). The patient was taken immediately to the cardiac catheterisation laboratory. Coronary angiography revealed an occluded proximal left anterior descending artery without collateral circulation. Intra‐aortic balloon pump counterpulsation failed to improve the haemodynamic status. With the patient in cardiogenic shock, a decision was made for percutaneous transcatheter closure as an alternative to urgent surgical repair. A 22 mm Amplatzer occluder device (AGA Medical Corporation, Minneapolis, Minnesota, USA) was placed via the femoral vein under combined fluoroscopic and RT3‐D echocardiographic guidance (panel C). Careful imaging was needed to identify ventricular septal tissue positioned between both discs. Placement of the occluder resulted in immediate clinical improvement and a decrease in the pulmonary artery oxygen saturation from 80% to 58%. After 6 weeks, the patient underwent successful surgical repair of a persistent small residual shunt for prognostic reasons.
Our case illustrates the clinical usefulness of RT3‐D echocardiography in defining the exact location of a postmyocardial infarction VSD, guiding the interventional closure, and immediately evaluating the result.
Real‐time three‐dimensional echocardiography. (A) Parasternal long‐axis view locating the through‐and‐through defect to the mid anteroseptal segment (arrow). (B) Colour flow imaging showing a large left‐to‐right shunt across the defect. (C) Deployment of both discs with the device still attached to the delivery cable. (D) Appropriate device position after release.
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