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Retrograde Closure of Post-Infarct Ventricular Septal Rupture to Avoid Moderator Band Entanglement
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A 63-year-old man presented with delayed inferior ST-elevation myocardial infarction complicated with ventricular septal rupture (VSR). He developed cardiogenic shock and respiratory failure requiring intubation and Impella (Abiomed) support. After discussion by the heart team, he was referred for percutaneous VSR closure 16 days after presentation.
Transesophageal echocardiography (TEE) and a left ventriculogram revealed a 15-mm VSR in the inferoseptal region. There was a thick moderator band next to the right ventricular (RV) exit site (Figure A and B). The VSR was crossed with a Judkins Right catheter and a Glidewire (Terumo) was snared in the left pulmonary artery, forming an arterial-venous loop. The Glidewire was then exchanged for an Amplatz Super Stiff guidewire (Boston Scientific) for antegrade passage of the 10-French 45° curved delivery sheath from the right femoral vein. A 22-mm Amplatzer Post-infarct Muscular Ventricular Septal Defect Occluder (Abbott) was delivered by antegrade approach. However, after left disc deployment, there was a cobra-neck deformity of the right disc due to entanglement between the device and the moderator band (Figure C and D).
Therefore, it was decided to deploy the same device by retrograde approach. Proper formation of the right disc was achieved despite some interaction with the moderator band. With further pulling, the right disc was freed from the moderator band and the VSR was successfully closed with minimal residual flow (Figure E and F, Video). The device remained stable in follow-up echocardiography and chest x-ray. Unfortunately, the patient succumbed to multiorgan dysfunction 5 days later.
Antegrade closure of VSR is the preferred strategy in most cases as it allows better anchoring and sealing of the VSR. However, deployment of right disc can sometimes be challenging due to apical position or orientation of the defect, as well as interaction with the moderator band in the RV, as in this case. Retrograde closure of the VSR with a symmetrical double-disc-designed device allows for proper formation of the right disc while avoiding entanglement with the moderator band.
Affiliations and Disclosures
From the Division of Cardiology, Queen Elizabeth Hospital, Hong Kong.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Ethical statement: 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.
Address for correspondence: Cheuk Bong Ho, MBBS, 30 Gascoigne Road, Jordon, Kowloon, Hong Kong. Email: bongii2001@gmail.com; X: @RonnieCB_Ho
