Transcatheter Management of Post Infarction Ventricular Septal Rupture With Concomitant Percutaneous Coronary Intervention

Introduction

Ventricular septal defect (VSD) or rupture (VSR) after acute myocardial infarction is an uncommon but catastrophic event with poor prognosis.^1-5 Immediate surgical closure with hemodynamic support (such as an intra-aortic balloon pump or IABP) is the treatment of choice as advised by the American College of Cardiology and American Heart Association (ACC/AHA).^6-9 Advanced patient age, hemodynamic instability, surgical challenges, and co-morbidities are still associated with high mortality rates.^2,5,10 Medical therapy alone has no role in improving survival and is associated with very poor prognosis.^11,12 Partial or complete closure of a VSR through a transcatheter approach appears to be very attractive alternative to surgery and is associated with much less mortality and morbidity, especially in experienced centers.^12-15 Herein, we share a case of a large VSR that was closed with an Amplatzer postinfarct muscular VSD device (PIMVSD) concomitantly with coronary intervention of a critically stenosed mid left anterior descending coronary artery (LAD). This is the first case in Iraq with critical coronary artery disease and large post myocardial infarction VSR that was managed through a transcatheter approach. The patient showed dramatic improvement after closure and on follow-up.

Case

A 68-year-old female patient with a history of hypertension and dyslipidemia presented to the emergency department with typical ischemic chest pain and electrocardiographic findings of anteroseptal ST-elevation myocardial infarction (STEMI). The patient received thrombolytic therapy, consequently had coronary angiography, and then was referred to our hospital 15 days post infarction, for further management. Transthoracic echocardiography revealed moderate left ventricular dysfunction, an ejection fraction of 40%, anteroseptal and apical akinesia, a small apical aneurysm, a large VSR (17 x 14 mm) with dominant left-to-right shunt, and a right ventricular systolic pressure of 45 mmHg (Figure 1). An informed consent was obtained and the patient was prepared for elective cardiac catheterization with a plan for transcatheter closure of the VSR. Under local anesthesia and with transthoracic echocardiographic guidance, right femoral and internal jugular vascular access was obtained, and selective left coronary artery and left ventricle (left anterior oblique [LAO]/cranial 35/35) angiography was performed (Figure 2). Angioplasty of the mid LAD was achieved successfully with 14 x 2 mm Resolute stent (Medtronic). The VSR was crossed from the left ventricle with a 6 French (Fr) cut pigtail and standard 0.35-inch Terumo wire advanced into the pulmonary artery. A manually modified 6 Fr multipurpose catheter was introduced through the internal jugular vein into the pulmonary artery where the Terumo wire had been snared and exteriorized. A 20 mm PIMVSD device  (AGA Medical) was advanced into the left ventricle. Under transthoracic echocardiographic and continuous hand injection through the already cut pigtail into the left ventricle, the device was completely deployed (Figure 3). At that time, a significant rise in the left ventricular systolic pressure was observed. Left ventricular angiography revealed a small, residual shunt. Only after device stability was assessed by left ventricular angiography and transthoracic echocardiography, was the device was released (Figures 4-5). The patient transferred to the intensive care unit and was discharged 3 days later in satisfactory condition. At 1- and 2-month post closure follow-up that included left ventricular angiography, the patient continued in stable condition and with slight decrement of the residual shunt.  

Discussion

Although surgical management of the VSR with concurrent coronary artery bypass grafting is the treatment of choice for post-infarction VSR, a significant percentage of patients still had a high mortality rate, particular those with hemodynamic instability, cardiogenic shock, and/or co-morbidities. Generally, closure of the ventricular septal rupture was either performed early after the acute myocardial infarction (at less than 14 days) which usually carries a high rate of mortality, or late (more than 14 days), which was associated with successful closure of greater than 70%.^9,11,15,16 Transcatheter closure with different types of devices has increasingly achieved a good alternative to surgical closure with high rate of closure and a much lower rate of early mortality.¹⁷ The aim of transcatheter closure may be only as a bridge to an urgent surgery or as definitive primary treatment with complete closure. Our case is the first case of post MI VSR in Iraq that was managed by a transcatheter approach with concomitant coronary intervention and VSR closure at the same session, with successful results. A small, hemodynamically non-significant residual shunt was detected on transthoracic echocardiography at 24 hours and at 2-month follow-up. The procedure went smoothly without significant complications. This may be related to the preparation and experience of the team involved in this case, which included coronary/structural and congenital interventionalists.

References  

1. Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation. 2000; 101: 27-32.
2. Deja MA, Szostek J, Widenka K, Szafron B, Spyt TJ, Hickey MS, Sosnowski AW. Post infarction ventricular septal defect – can we do better? Eur J Cardiothorac Surg. 2000; 18: 194-201.
3. Mantovani V, Mariscalco G, Leva C, Blanzola C, Sala A. Surgical repair of post-infarction ventricular septal defect: 19 years of experience. Int J Cardiol. 2006 Apr 4; 108(2): 202-206.
4. Labrousse L, Choukroun E, Chevalier JM, et al. Surgery for post-infarction ventricular septal defect (VSD): risk factors for hospital death and long term results. Euro J Cardiothor Surg. 2002; 21: 725-732.
5. Jeppsson A, Liden H, Johnsson P, Hartford M, Radegran K. Surgical repair of post infarction ventricular septal defects: a national experience. Euro J Cardiothor Surg. 2005; 27: 216-221. 
6. Ryan TJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1999; 34(3): 890-911.
7. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction - executive summary. Circulation. 2004; 110: 588-636.
8. Thiele H, Lauer B, Hambrecht R, Boudriot E, Sick P, Niebauer J, et al. Short- and long-term hemodynamic effects of intra-aortic balloon support in ventricular septal defect complicating acute myocardial infarction. Am J Cardiol. 2003; 92: 450-454
9. Maltais S, Ibrahim R, Basmadjian AJ, et al. Postinfarction ventricular septal defects: towards a new treatment algorithm? Ann Thorac Surg. 2009; 87(3): 687-692.
10. Menon V, Webb JG, Hillis LD, Sleeper LA, Abboud R, Dzavik V, et al. Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize Occluded Coronaries in cardiogenic shock? J Am Coll Cardiol. 2000; 36: 1110-1116. 
11. Thiele H, Kaulfersch C, Daehnert I, Schoenauer M, Eitel I, et al. Immediate primary transcatheter closure of postinfarction ventricular septal defects. Eur Heart J. 2009; 30(1): 81-88.
12. Calvert PA, Cockburn J, Wynne D, Ludman P, Rana BS, Northridge D, et al. Percutaneous closure of postinfarction ventricular septal defect: in-hospital outcomes and long-term follow-up of UK experience. Circulation. 2014; 129: 2395-2402.
13. Marinakis A, Vydt T, Dens J, Gewillig M, Van Deyk K, et al. Percutaneous transcatheter ventricular septal defect closure in adults with Amplatzer septal occluders. Acta Cardiol. 2007; 62(4): 391-395.
14. Jacek B, Malgorzata S, Jacek K, Zbigniew K, Mariusz G. Transcatheter closure of postinfarction ventricular defects using Amplatzer devices. Rev Esp Cardiol. 2007; 60(5): 548-551.
15. Ahmed J, Ruygrok PN, Wilson NJ, Webster MW, Greaves S, et al. Percutaneous closure of post-myocardial infarction ventricular septal defects: a single centre experience. Heart Lung Circ. 2008; 17(2): 119-123.
16. Goldstein JA, Casserly IP, Balzer DT, et al. Transcatheter closure of recurrent postmyocardial infarction ventricular septal defects utilizing the Amplatzer postinfarction VSD device: a case series. Catheter Cardiovasc Interv. 2003; 59(2): 238-243.
17. Nikolaos K, Brecker SJD. Device closure for ventricular septal defect after myocardial infarction: an overview of the potential use of transcatheter options to treat anatomically suitable patients with postmyocardial infarction VSD. Cardiac Interventions Today. 2009 Nov: 43-49. Available online at https://citoday.com/pdfs/1109_07.pdf. Accessed August 25, 2016

Najaf Cardiac Center in An Najaf, Iraq, is a referral center performing 5000 cases/year.

Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted at khalidamber4@gmail.com.