Closure of Post-Myocardial Infarction Ventricular Septal Defect with Use of Intracardiac Echocardiographic Imaging and Percutaneous Left Ventricular Assistance

Abstract

WEBSITE FEATURE

A 67-year-old man presented at another hospital with an anterior-wall myocardial infarction. He was transferred to our institution after he went into progressive cardiogenic shock and developed a post-myocardial infarction apical ventricular septal defect (VSD). During high-dose inotropic support, his blood pressure was 78/34 mmHg. Cardiac catheterization revealed a pulmonary artery pressure of 71/30 (48) mmHg and a Qp/Qs ratio of 3.75:1. The cardiogenic shock was refractory, so a TandemHeart® percutaneous ventricular assist device (CardiacAssist, Inc.; Pittsburgh, Pa) was implanted. The patient's left atrial pressure is shown in Figure 1. Intracardiac echocardiography from the right ventricle was used to inspect the left ventricle and the VSD (Figs. 2 and 3). A sagittal view of the septum enabled accurate measurement of the defect (Figs. 4 and 5). On the basis of compassionate use, percutaneous closure of the VSD was performed with a 24-mm Amplatzer® postinfarction VSD occluder (St. Jude Medical, Inc.; St. Paul, Minn) (Fig. 6). A small residual leak was noted. Three weeks after the procedure, the patient died of pancreatitis. The VSD was clearly visible at autopsy (Fig. 7).

Fig. 1 Hemodynamic recording shows the patient's left atrial pressure.

Fig. 2 Intracardiac echocardiogram from the right ventricle shows the left ventricle and the ventricular septal defect.

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Fig. 3 Intracardiac echocardiogram with color-flow Doppler shows the left ventricle and the ventricular septal defect.

Real-time motion image is available at www.texasheart.org/journal.

Fig. 4 Intracardiac echocardiogram (sagittal view) shows the ventricular septal defect (arrow).

Real-time motion image is available at www.texasheart.org/journal.

Fig. 5 Intracardiac echocardiogram with color-flow Doppler shows the septum. The sagittal view enabled accurate measurement of the ventricular septal defect.

Real-time motion image is available at www.texasheart.org/journal.

Fig. 6 Percutaneous closure of the ventricular septal defect (VSD) was performed with a 24-mm Amplatzer® VSD occluder.

Real-time motion image is available at www.texasheart.org/journal.

Fig. 7 Photographs at autopsy show A) the closed ventricular septal defect and B) the heart after removal of the occluder device.

Comment

Rupture of the interventricular septum after ST-segment-elevation myocardial infarction is a devastating sequela: the associated 30-day mortality rate is 74%.¹ Affected patients usually go into cardiogenic shock within hours or days. Emergent cardiac surgery is indicated, although the perioperative risk of death is very high.

Percutaneous transcatheter closure of a postinfarction VSD is performed in only a few centers worldwide. The TandemHeart device provided significant and perhaps life-saving hemodynamic support during VSD closure in our patient. In addition, the percutaneous closure was greatly facilitated by the intracardiac echocardiographic sagittal view, which revealed that the ventricular septum was perforated. To our knowledge, this is the first described use of the sagittal view of intracardiac echocardiography in this situation. We believe that TandemHeart-assisted percutaneous closure of a postinfarction VSD, with guidance enabled by intracardiac echocardiography in sagittal view, can lower mortality rates in patients with a postinfarction VSD.

Acknowledgments

We thank Nicole Stancel, PhD, ELS, and Stephen N. Palmer, PhD, ELS, of the Texas Heart Institute at St. Luke's Episcopal Hospital, for editorial assistance with this manuscript.