RC is a 57 year old Filipino male admitted to the ICU and managed as one vessel coronary artery disease and ventricular septal defect. He was previously diagnosed as anterior wall STEMI but medically managed. There was a grade 4/6 holosystolic murmur on the left sternal border. He had hypotension with BP of 80/60 mmHg with worsening of dyspnea during ICU stay and underwent emergency IABP insertion with percutaneous closure of the VSR using an ASD occluder device with no complications.

Transthoracic echocardiogram showed an echo dropout seen at the apical portion of the interventricular septum measuring 1.44cm. There was hypokinesia of the basal and mid anterior septum, apical lateral segment and mid anterior segment with akinesia of the apical septal segment, apical anterior and apex with ejection fraction of 35%. Myocardial perfusion scan showed mainly scarred anterior, septal and lateral myocardium.

The coronary angiogram showed a left anterior descending artery with a 95% mid segment stenosis. Intra-aortic balloon pump was inserted. Left Ventriculogram showed contrast extravasation into the right ventricle from the left ventricle. Pressure recordings showed an elevated pulmonary artery pressure of 73/31 mmHg, elevated RV systolic pressure at 80 mm Hg. Oximetry saturation showed a step up in the right ventricle with 91% saturation and mixed venous oxygen saturation of 61%

A right femoral arterial access and a right internal jugular venous access was obtained. Left ventriculography was done on LAO 30 and Cranial 30 projection to outline the defect. A transesophageal echocardiogram was also used to accurately assess the ventricular septal defect. A modified 6F pigtail catheter with a hydrophilic wire was used to cross the defect while using a snare system to externalize the wire from the right internal jugular vein to obtain an arteriovenous circuit. The delivery system was then advanced from the right internal jugular vein and across the defect until the tip was at the left ventricle. An atrial septal defect occluder 36 mm was used and advanced to the defect. The distal disk was opened and gently pulled back while the sheath was slowly retracted with eventual complete deployment of the device. A repeat left ventriculogram showed no contrast extravasation across the defect with confirmation on transesophageal echocardiogram. The device was then released by turning counterclockwise.

Surgical management is the mainstay for treatment for ventricular septal rupture but appropriate timing has been difficult.  A percutaneous approach has been developed to provide a definitive treatment or bridge to surgery. This case highlights that a primary transcatheter closure using an ASD occlusion device for ischemic ventricular septal defect can be a safe and feasible definitive option. Timely closure of the left to right shunt has improved systemic circulation with decrease in heart failure symptoms leading to improved clinical status and eventual discharge.