TCTAP & AP VALVES 2020 Virtual

CASE20191031_036

STRUCTURAL HEART DISEASE - Others (STRUCTURAL HEART DISEASE)
Post Myocardial Infarction Ventricular Septal Rupture with Heart Failure Treated Successfully by Device Closure
Davinder Singh Chadha¹, Keshavamurthy G²
Manipal Hospital, India¹, Ahrr, India²,

[Clinical Information] - Patient initials or identifier number: VDVL -Relevant clinical history and physical exam: 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. -Relevant test results prior to catheterization: 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.Patient was discussed in 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. POST MI VSD F_O NC VADIVEL20180920174551997 (Converted).mov - Relevant catheterization findings: 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. LV Angio (Converted).mov
[Interventional Management] - Procedural step: 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 18mm Amplatzer Muscular VSD device was loaded on to 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 hospital. Doing well after 12 months now in NYHA class I. Device deployed in VSR (Converted).mov Device released (Converted).mov Echo post closure Follow up VSR (Converted).mov - Case Summary: Ventricularseptal rupture (VSR) is a rare but life-threatening complication of acute myocardialinfarction. Wherever feasible, complete revascularisation andstabilization should be done before attempting closure of VSR to allow themargins of VSR to heal and become firm. In this patient we performedmultivessel PCI (TVD) and stabilized heart failure before device closure. Oneneeds to oversize the device by at least 4-6 mm unlike congenitalVSD. Ideally Post MI VSR device to be used which has wider LV discand longer waist. One need not chase small residual shunts. Theyare hemodynamically insignificant and usually close over a period oftime.

E-Science Station