VDVL

A 69-year-old gentleman, tobacco chewer, presented with anginal chest pain of 8 hours duration. Clinically he had tachycardia. Other vitals and systems- unremarkable. ECG showed ST elevation in leads II, III and AVF. 2D Echocardiography showed RWMA in inferior wall with LVEF 55%. He was immediately taken up for Primary Angioplasty.CAG showed TVD. PAMI + DES to RCA was done. Subsequently staged PCI to LAD and LCX were done. After 2 months he presented with sudden onset heart failure and PSM. 

Echocardiography showed 14 mm Ventricular Septal Rupture in apical inferior septum with left to right shunt. PA pressure was 60 mmHg.A diagnosis of Post Myocardial Infarction Ventricular Septal Rupture with Heart Failure and PAH was made.The patient was discussed in a heart team meeting and it was decided to stabilize the patient with anti-heart failure therapy. After stabilization it was planned to try transcatheter device closure; if unsuccessful, open surgical closure was the standby option.
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After 3 weeks of anti-failure therapy, he was taken up for percutaneous device closure of Ventricular Septal Rupture (VSR). PA pressure was 55/30 mmHg. Step up in oxygen saturation was noted in RV apex. Qp/Qs was 2:1. Left Ventricular angiography in LAO Cranial 40⁰- 30⁰  showed Ventricular Septal Rupture near apex with left right shunt.
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The procedure was meticulously planned including access, hardware, possible complications, and solutions. Surgical team was kept stand by. It was decided to establish arteriovenous loop from right femoral artery to right internal jugular vein (RIJV) so that it becomes easier to negotiate apical VSR while bringing delivery sheath from RIJV.Accesses were: Right Femoral Artery (RFA) -6F, Right Femoral Vein (RFV)- 6F. Right internal jugular vein (RIJV) – 6F. VSD crossed with exchange length 0.035” Terumo glide wire taken in a JR 6F guiding catheter. Terumo wire negotiated into PA. It was snared from Rt IJV through a gooseneck snare and exteriorized. Thus AV Loop established. Thereafter 18 mm Amplatzer Muscular VSD device was loaded onto a 9F loader. 9F delivery sheath taken over Terumo wire into LV. Terumo removed. Device loaded into delivery sheath and taken to LV. LV disc deployed in LV. Device pulled back into VSD and RV disc deployed. Check angio showed minimal residual flow across. Echo also showed snuggly fitting device across VSR. Device released. Procedure completed without any complications.Three days later, Echo showed complete closure of VSR without any residual flow.Subsequently patient walked out of the hospital. Doing well after 12 months now in NYHA class I
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Ventricular Septal Rupture(VSR) is a rare but life-threatening complication of Acute Myocardial Infarction. Wherever feasible, complete revascularisation and stabilization should be done before attempting closure of VSR to allow the margins of VSR to heal and become firm. In this patient, we performed multivessel PCI(TVD) and stabilized heart failure before device closure. One needs to oversize the device by at least 4-6 mm unlike congenital VSD.  Ideally, post MI VSR device to be used which has a wider LV disc and longer waist.One need not chase small residual shunts. They are hemodynamically insignificant and usually close over a period of time.