Transcatheter closure of ventricular septal rupture with prolonged support of intra-aortic balloon pump after primary PCI: a case report.

BACKGROUND: Ventricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases. CASE PRESENTATION: A 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2-3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction. CONCLUSIONS: Prolonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.

The Clinical Characteristics of Acute Myocardial Infarction with Ventricular Septal Perforation and the Prognosis Comparison of Different Treatment Methods.

OBJECTIVE: To explore the clinical characteristics of acute myocardial infarction (AMI) with ventricular septal perforation (VSR), the prognosis comparison of different treatment methods, and analysis of related risk factors. METHODS: From January 2006 to February 2020, 29 patients with AMI and VSR diagnosed in the People's Hospital of Peking University were selected as the study group. Among them, 16 cases were male (55.2%), 13 cases were female (44.8%), and the average age was 64.69 ± 10.32 years old. They were divided into two groups: the survival group (N = 16) and non-survival group (N = 13), according to whether they survived within 30 days of surgical or drug conservative treatment. The clinical characteristics, coronary angiography, and treatment of the two groups were summarized, and the prognosis and related risk factors were analyzed. RESULTS: There was no significant difference in the basic clinical characteristics between the two groups (P > 0.05). Compared with the results of coronary angiography in the two groups, the proportion of the culprit vessel, which was a simple anterior descending branch in the non-survival group, was higher than that in the survival group. There was a statistical difference between the two groups (P < 0.05). The perioperative data of the two groups showed that the proportion of patients with complete revascularization, simultaneous bypass, and recanalization of culprit vessels in the survival group was significantly higher than that in the non-survival group (P < 0.05). However, the incidence of postoperative low cardiac output and mortality during hospitalization in the survival group were significantly lower than those in the non-survival group (P < 0.05). Logistic regression analysis showed that complete revascularization (OR = 0.021, 95% CI 0.001-0.374, P = 0.009) and recanalization of culprit vessels (OR = 0.045, 95% CI 0.004-0.548, P = 0.015) were independent risk factors for 30-day mortality. Kaplan-Meier survival curve showed that during the follow-up period, the long-term survival rate of patients with operation and complete revascularization was significantly higher than that of patients with drug conservative treatment and incomplete revascularization. There was a statistical difference between the two groups (P < 0.05). CONCLUSION: Complete revascularization and recanalization of culprit vessels are independent risk factors for 30-day mortality in patients with AMI and VSR. The long-term survival rate of patients after surgery and complete revascularization is significantly higher than that of patients with conservative medical treatment and incomplete revascularization. Surgery and complete revascularization are important factors affecting the long-term prognosis of patients with AMI and VSR.

Ventricular septal rupture with right ventricular wall dissection after inferior ventricular infarction: A case report and literature review.

Right ventricular (RV) wall dissection following ventricular septal rupture related to inferior myocardial infarction (MI) is an extremely rare complication with a high mortality rate. We report the case of a 61-year-old man who was admitted to our hospital because of syncope and intermittent chest pain with a precordial murmur. Transthoracic echocardiography showed a rupture at the basal infero-posterior septum and RV free-wall dissection forming an echolucent cavity that extended beyond the septum and subsequently re-entered into RV chamber. The patient's overall cardiac and renal functions deteriorated and he died 24 days after the diagnosis. We present a literature review of the published cases of complex dissecting tracts through the septum and RV wall in ischemic context.

Ventricular septal rupture complicating acute myocardial infarction: Incidence, treatment, and outcomes among medicare beneficiaries 1999-2014.

OBJECTIVES: The present study was designed to assess whether the incidence and outcomes of VSR-AMI have changed in the era of timely primary PCI. BACKGROUND: Ventricular septal rupture (VSR) is a rare but frequently fatal complication of acute myocardial infarction (AMI). METHODS: We conducted a retrospective cohort study of all Medicare fee-for-service beneficiaries from 1999 to 2014 to examine trends in the incidence, surgical and percutaneous repair, and 30-day and 1-year mortality of VSR-AMI. RESULTS: The annual incidence of VSR-AMI hospitalization declined by 41.6% from 197 patients per 100,000 AMIs in 1999 to 115 patients per 100,000 AMIs in 2014 (P < 0.001). The 30-day VSR-AMI repair rate decreased from 49.9% in 1999 to 33.3% in 2014 (P < 0.001). In 2014, 82.9% of repairs were performed surgically and 17.1% percutaneously. VSR-AMI mortality rates were high (60.2% at 30 days; 68.5% at 1 year) and changed minimally over the study period with adjusted 30-day mortality per year Odds Ratio (OR) 0.99 (95% confidence interval [CI] 0.98-1.01) and adjusted 1-year mortality per year OR 0.98 (95% CI 0.97-1.00). Across the 16 years of data, unadjusted mortality rates were lower in patients undergoing repair than in unrepaired patients at 30 days (mean 51.7% and 65.7%, P ≤ 0.01) and 1 year (mean 62.0% and 72.8%, P < 0.01). CONCLUSIONS: In the era of increased timely primary PCI, the incidence of VSR-AMI hospitalization declined but its associated mortality rate remained high. Rates of VSR repair decreased from 1999 to 2014 despite increased use of percutaneous repair.

ECMO as a bridge to non-transplant cardiac surgery.

Cardiac surgery performed on patients in cardiogenic shock is associated with a high mortality and morbidity. This review outlines the current role of preoperative veno-arterial extra corporeal membrane oxygenation to allow hemodynamic stability and organ recovery before definitive cardiac surgery.

Intra-aortic balloon pump insertion through the right subclavian artery in a patient of anterior wall myocardial infarction with ventricular septal rupture and severe peripheral artery obstruction disease.

Intra-aortic balloon pump (IABP) is used in cardiogenic shock of different etiologies. Routinely, it is inserted through the transfemoral access, but in the patients with severe peripheral artery obstruction disease (PAOD), use of alternative approach is needed. In this case report, IABP insertion through the right subclavian artery with the help of cardiothoracic surgeon in a patient of anterior wall myocardial infarction (AWMI) with severe PAOD has been described. A 60-years-old male patient, with the history of chronic smoking, presented with progressing chest pain for last 3 days. On the basis of clinical examination and radiological findings, he was diagnosed with AWMI along with the ventricular septal rupture and PAOD. The patient was advised to undergo coronary artery bypass graft with VSR repair, but to stabilize the patient, it was necessary to put him on IABP. Because of the severe PAOD, femoral access was not suitable to insert the IABP, and hence, the right subclavian route was accessed. Then, the patient was operated and no other complications were encountered. Subclavian arterial IABP insertion under local anesthesia is easier and safer to perform and allows increased patient mobility. Other routes, such as, ascending aorta and axillary artery have also been discussed in other literatures, but subclavian arterial IABP insertion was found to be the best in the patients with severe PAOD. Trans-subclavian route is an effective approach in extended IABP utilization even in patients with severe PAOD. © 2014 Wiley Periodicals, Inc.

Transcatheter closure of postmyocardial infarction, iatrogenic, and postoperative ventricular septal defects: The Mayo Clinic experience.

OBJECTIVES: To determine event-free survival after transcatheter closure of ventricular septal defect (VSD), and to identify predictors of adverse events (AE) in post myocardial infarction VSD (post-MI VSD) subgroup. BACKGROUND: There are limited data on mid-term follow-up after transcatheter VSD closure. METHODS: Retrospective review of 27 cases of transcatheter VSD closure (post-MI = 18 and non-ischemic = 9) performed from 1999 to 2013. We defined AE as death, device embolization, hemolysis requiring blood transfusion, heart block and reintervention. RESULTS: In the post-MI VSD subgroup, mean age and follow-up was 69 ± 11 and 7.3 ± 7 years, respectively. AE occurred in 8 (44%) patients (death-3, device embolization-1, hemolysis-1, surgical VSD closure-2, reintervention-1). Event-free survival was 56% at 1 month and 5 years, and all AE occurred in the periprocedural period. Cardiogenic shock (HR: 3.21, CI: 1.82-5.41, P = 0.002), and VSD closure in acute phase (HR: 2.14, CI: 1.12-4.31, P = 0.004) were independent predictors of AE. In the non-ischemic VSD subgroup, mean age and follow-up was 49 ± 15 and 8.7 ± 8 years, respectively. AE occurred in 3 (33%) patients (late death-1, surgical VSD closure-2). For the entire cohort, freedom from death was 89% and 85% at 1 month and 5 years, and event-free survival was 70% and 61% at 1 month and 5 years. CONCLUSIONS: Transcatheter closure of post-MI VSD carries a moderate risk of periprocedural complications but low event rates afterwards. By comparison, device closure of non-ischemic VSD has lower periprocedural morbidity but some patients continued to experience AE during follow-up.

Ventricular septal rupture complicating acute myocardial infarction: a contemporary review.

Ventricular septal rupture (VSR) after acute myocardial infarction is increasingly rare in the percutaneous coronary intervention era but mortality remains high. Prompt diagnosis is key and definitive surgery, though challenging and associated with high mortality, remains the treatment of choice. Alternatively, delaying surgery in stable patients may provide better results. Prolonged medical management is usually futile, but includes afterload reduction and intra-aortic balloon pump placement. Using full mechanical support to delay surgery is an attractive option, but data on success is limited to case reports. Finally, percutaneous VSR closure may be used as a temporizing measure to reduce shunt, or for patients in the sub-acute to chronic period whose comorbidities preclude surgical repair.

Ventricular Septal Rupture After Myocardial Infarction: JACC Focus Seminar 3/5.

Ventricular septal rupture remains a dreadful complication of acute myocardial infarction. Although less commonly observed than during the prethrombolytic era, the condition remains complex and is often associated with refractory cardiogenic shock and death. Corrective surgery, although superior to medical treatment, has been associated with high perioperative morbidity and mortality. Transcatheter closure techniques are less invasive to surgery and offer a valuable alternative, particularly in patients with cardiogenic shock. In these patients, percutaneous mechanical circulatory support represents a novel opportunity for immediate stabilization and preserved end-organ function. Multimodality imaging can identify favorable septal anatomy for the most appropriate type of repair. The heart team approach will define optimal timing for surgery vs percutaneous repair. Emerging concepts are proposed for a deferred treatment approach, including orthotropic heart transplantation in ideal candidates. Finally, for futile situations, palliative care experts and a medical ethics team will provide the best options for end-of-life clinical decision making.

[Percutaneous treatment of post-acute myocardial infarction mechanical complications: state of the art]. / Trattamento percutaneo delle complicanze meccaniche dell'infarto miocardico acuto: stato dell'arte.

Left ventricular free wall rupture, ventricular pseudoaneurysm, papillary muscle rupture and ventricular septal rupture are life-threatening mechanical complications of acute myocardial infarction. Despite significant improvements over the last decades in overall mortality for patients with myocardial infarction, the outcome of subjects who develop post-infarction mechanical complications remains poor. Surgical treatment is considered the standard of care. However, percutaneous approaches (such as pericardial fibrin-glue injection for left ventricular free wall rupture, transcatheter edge-to-edge mitral repair for papillary muscle rupture and device closure for ventricular pseudoaneurysm or septal rupture) have been proposed in selected high-risk or inoperable patients, or in subjects with ideal characteristics for feasibility, as therapeutic alternatives to open surgery. The aim of the present review is to provide a comprehensive overview of the percutaneous strategies for the management of post-acute myocardial infarction mechanical complications.

Percutaneous ventricular septal defect closure with Amplatzer devices resulting in severe tricuspid regurgitation.

While percutaneous intervention is an alternative for patients who are not surgical candidates, the rate of morbidity and mortality is comparable to open repair. Appending the reported complications associated with percutaneous intervention (device mal-positioning, dislodgement, and entrapment in the sub-valvular apparatus), we report mechanical damage to the tricuspid valve (TV). Percutaneous closure with an Amplatzer septal occluder device was attempted on three patients who developed a ventricular septal defects (VSD) after myocardial infarction. In all three cases, damage to the tricuspid leaflet was noted post-procedure. The accompanying severe tricuspid regurgitation led to right ventricular failure, even in the patients where the VSD was considered successfully occluded. Despite successful deployment of the Amplatzer device, complications with catheter manipulation may still arise. Damage to the TV can occur during percutaneous VSD closure with Amplatzer device. Periprocedure TEE monitoring can detect damage to the tricuspid leaflets.

Left-to-right shunt reduction with intra-aortic balloon pump in postmyocardial infarction ventricular septal defect.

This case aims to describe the hemodynamic effects of intra-aortic balloon pump (IABP) in patients with ventricular septal defect (VSD) complicating myocardial infarction (MI). A 79-year-old man with no previous cardiovascular history presented to the emergency department with subacute inferior myocardial infarction associated with mild signs of systemic hypoperfusion. A transthoracic echocardiography revealed a large akinesia of the left ventricular inferior wall with preserved global left ventricular ejection fraction, as well as a large VSD in the midinferior portion of the interventricular septum. Coronary angiography showed an occlusion of the mid portion of a dominant circumflex coronary artery. The invasive hemodynamic evaluation showed a sizable left-to-right shunt (Q(p)/Q(s) = 3.1). Activation of the IABP led to an immediate reduction of the shunt (Q(p)/Q(s) = 2.4 = 22% reduction), an increase in systemic cardiac output (from 2.1 L/min to 2.4 L/min = +12%) and a decrease in the systemic vascular resistances (from 2240 to 1920 dyne-sec/cm(5) = 15% reduction). In patients with post-MI VSD, placement of IABP leads to an immediate reduction in left-to-right shunt and as a consequence to an increase in systemic cardiac output, which may allow hemodynamic stabilization of the patient prior to surgical VSD closure.

Extracorporeal membrane oxygenation as a temporizing approach in a patient with shock, myocardial infarct, and a large ventricle septal defect; successful repair after six days.

Rupture of the ventricular septum occurs in 1% to 2% of all acute myocardial infarctions (MI) requiring surgical intervention in the majority of cases. Furthermore, patch dehiscence and residual shunt are major problems following repair in the acute stage. A delay in repair may prevent patch dehiscence. We now describe the technique used for a successful repair of a ruptured ventricular septal defect following six days of extracorporeal membrane oxygenation support.

Percutaneous ventricular assist device and extracorporeal membrane oxygenation support in a patient with postinfarction ventricular septal defect and free wall rupture.

We describe the case of a 54-year-old woman with a postinfarction ventricular septal defect (VSD) and ventricular free wall rupture who was stabilized with a percutaneous ventricular assist device (pVAD) to allow for myocardial infarct stabilization. Following the rupture of the right ventricular free wall and cardiopulmonary arrest on hospital day 10, pVAD support was promptly converted to extracorporeal membrane oxygenation (ECMO) support for stabilization. After surgical repair was completed, pVAD support was continued for 4 days to allow recovery. The patient was discharged on postoperative day 11 and is alive and well 4 years later. Postinfarction VSD with free wall rupture may be salvaged with pVAD and ECMO support.

Ventricular septal rupture caused by myocardial bridge, solved by interventional closure device.

Myocardial bridging is a common coronary anomaly, which is generally described as a benign phenomenon. However, a growing number of studies consider this anomaly a relevant pathophysiological phenomenon with serious pathological consequences. Here we report on the case of an 88-year-old woman suffering from myocardial infarction and ventricular septal rupture, lacking any recognizable coronary disease except for a myocardial bridge causing the systolic compression of the left anterior descending coronary artery. A wide range of diagnostic procedures, including coronarography, echocardiography, and magnetic resonance imaging were used. The septal rupture was finally closed by using a percutaneous closure device. This event indicates that myocardial bridges - at least in some cases - may have notable clinical relevance.

Sutureless Patch Repair With a Novel Adhesive for Postinfarction Ventricular Septal Rupture.

Ventricular septal rupture after acute myocardial infarction is a fatal complication with a very high in-hospital mortality. Herein, we describe a new repair technique using a first patch for exclusion of the infarcted myocardium and a second sutureless patch for rupture site closure with a novel tissue adhesive (Hydrofit, Terumo, Tokyo, Japan). Follow-up of over 2 years revealed a good clinical course and no residual interventricular shunt on echocardiography. This modified infarct exclusion technique with a second sutureless patch has a benefit of avoiding stitches to the fragile infarcted myocardium and might be effective in preventing interventricular shunt recurrence after ventricular septal rupture.

Management and outcome of post-myocardial infarction ventricular septal rupture-A Low-Middle-Income Country Experience.

BACKGROUND: Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (AMI) especially in the reperfusion era but its associated mortality has remained high. This case series evaluated in-hospital and intermediate-term mortality in VSR patients. Additionally, we also analyzed risk factors, clinical presentation, intervention, and predictors of in-hospital mortality in VSR patients. METHODS: Data of 67 patients with echocardiography confirmed diagnosis of VSR from January 2011 to April 2020 was extracted from hospital medical records. Records were also reviewed to document 30 day and 1-year mortality, recurrent heart failure admission, repeat myocardial infarction, and revascularization. In addition, telephonic follow-up was done to assess health-related quality of life(HRQOL) assessed by KCCQ-12. SCAI shock classification was used to categorize severity of cardiogenic shock. Univariate and multivariable logistic regression was used to determine predictors of in-hospital mortality. Survival function was presented using the Kaplan-Meier survival curve. RESULTS: Mean age of patients was 62.7 ± 11.1 years, 62.7% were males. 65.7% of the patients presented more than 24 hours after MI and did not receive reperfusion therapy. Median time from AMI to VSR diagnosis was 2 (1-5) days. VSR closure was attempted in 53.7% patients. In-hospital mortality was 65.7%. At univariate level, predictors of in-hospital mortality were non-surgical management, basal VSR, right ventricular dysfunction, early VSR post-MI, and severe cardiogenic shock at admission (class C, D, or E). Adjusted predictors of in-hospital mortality included non-surgical management, basal VSR and advanced cardiogenic shock. There were 5 deaths during median followup of 44.1 months. HRQOL in patients available on followup was good (54.5%) or excellent (45.5%). CONCLUSION: High in-hospital mortality was seen in VSR patients. VSR closure is the preferred treatment to get long-term survival, however, timing of repair as well as severity of cardiogenic shock plays a significant role in determining prognosis.