Author + information
- Received October 9, 2017
- Revision received October 24, 2017
- Accepted October 24, 2017
- Published online April 16, 2018.
- Hope Caughron, BAa,
- Norihiko Kamioka, MDa,
- Christina E. Saikus, MD, PhDb,
- Stamatios Lerakis, MDa,
- Peter Block, MDa,
- Vasilis Babaliaros, MDa and
- Robert Guyton, MDb,∗ ()
- aDivision of Cardiology, Emory University School of Medicine, Atlanta, Georgia
- bDivision of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
- ↵∗Address for correspondence:
Dr. Robert Guyton, Emory University School of Medicine, 550 West Peachtree Street, Room 6059, Atlanta, Georgia 30308.
A 63-year-old man was transferred to our hospital 5 weeks after an acute anterior myocardial infarction complicated by an apical ventricular septal defect (VSD). He was on intravenous dopamine and required an intra-aortic balloon pump for hemodynamic stability.
A large peri-infarct area with a apical-septal VSD 1.4 cm in diameter (pulmonary flow/systemic flow 2.2, right ventricular [RV] systolic pressure 52 mm Hg) was confirmed on cardiac computed tomography (Figure 1A) and transthoracic echocardiogram (Figures 1B and 1C). The defect lacked an apical septal rim, which prevented traditional anchoring of a transcatheter device. As the patient was 5 weeks post-infarct, he had an increased likelihood of successful VSD closure and therefore a new hybrid technique was used to anchor a transcatheter atrial septal occluder.
The patient was taken to the hybrid operating room where, under general anesthesia, a left subcostal incision was made (1). A micropuncture technique was used and a soft guidewire was passed from the RV free wall through the center of the VSD using fluoroscopy, epicardial echocardiography, and transesophageal echocardiography guidance. The soft wire was advanced antegrade to the ascending aorta, for enhanced stability, and exchanged for a stiff guidewire. A 12-F sheath was passed over the stiff guidewire into the left ventricle (LV) and a 22-mm Amplatzer atrial septal occluder (left disc diameter 36 mm, right disc diameter 32 mm) (St. Jude Medical, St. Paul, Minnesota) was advanced through the sheath. The left side of the device was deployed in the LV and pulled against the LV side of the VSD (Figure 1D). Wrapped around the external portion of the sheath was a preloaded collar of 3 layers of Teflon felt (9 mm in diameter) used to secure the externalized device and prevent device retraction into the RV (Figure 2A). An additional 2 layers of Teflon felt (25 mm in diameter) served as a platform for the collar against the RV and aided in hemostasis (Figure 2A). The preloaded felt collar and platform were pushed against the external wall of the RV, while the right-side portion of the septal occluder was elongated and exteriorized (Figures 1E, 1F, 2B, and 3A). Thus, 1 cm of the device was within the platform and an additional 1 cm protruded into the pericardial space (Figures 1F and 3). The device was oversewn and secured with sutures through the platform, collar, and elongated disk (Figures 1F, 3A, and 3B). Post-operatively, there was only a 1.4:1 residual shunt superior to the device (RV systolic pressure 42) (Figure 3C). The patient had symptomatic improvement off dopamine and the intra-aortic balloon pump and did not have any post-procedural ventricular arrhythmia. He returned home after 9 days and his symptoms remained stable at a 1-month post-procedural follow-up without evidence of pericarditis or mechanical inflammation from the device. Further follow-up is required to determine the long-term effectiveness of this technique and whether the externalized device causes mechanical irritation of the surrounding tissues.
Although a direct periventricular approach is frequently used in congenital VSD closure, it has not been reported in post-ischemic VSD closure (2). This hybrid method may facilitate treatment of post-ischemic apical VSDs that frequently challenge present transcatheter strategies due to the lack of an unobstructed rim in the RV for device anchoring (2,3). In our case, a novel strategy was used to anchor the right side of the device by externalizing it through the RV wall. This allowed the device to compress the apical RV against the apical septum, resulting in partial RV exclusion and enhanced occlusion of the VSD. Similar to the common surgical patch technique, this hybrid strategy may be beneficial in both congenital and post-infarct apical VSD closure (4,5).
Dr. Babaliaros has served as a consultant for Abbott Vascular and Edwards Lifesciences. Dr. Guyton has served as a national surgical principal investigator for the Edwards Transcatheter Mitral Valve Replacement trial. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 9, 2017.
- Revision received October 24, 2017.
- Accepted October 24, 2017.
- 2018 American College of Cardiology Foundation
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