Author + information
- Received May 28, 2015
- Revision received June 25, 2015
- Accepted July 2, 2015
- Published online December 21, 2015.
- Richard Cheng, MD∗,
- Reza Arsanjani, MD∗,
- Emily Tat, BA∗,
- Justin Cox, MD∗,
- Abhimanyu Uberoi, MD, MS∗,
- Rebecca Aron, MD† and
- Saibal Kar, MD∗∗ ()
- ∗Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
- †Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
- ↵∗Reprint requests and correspondence:
Dr. Saibal Kar, Division of Cardiology, Cedars-Sinai Heart Institute, 8631 West Third Street, Suite 415E, Los Angeles, California 90048.
A 58-year-old male patient presented with an inferior ST-segment elevation myocardial infarction complicated by a ventricular septal defect (VSD). The VSD was surgically repaired, but basal extension of necrotic tissue obligated a second repair 2 weeks later. Subsequently, he again presented in cardiogenic shock and was found to have a significant residual VSD; he was referred to our institution for cardiac transplantation.
Transthoracic echocardiogram showed further basal extension of the VSD (Figure 1A) with left ventricular (LV) to right ventricular shunting. However, transesophageal echocardiogram instead revealed LV to right atrial (RA) shunting through an 11-mm Gerbode defect with direct extension through the atrioventricular portion of the septum, which was thought to be from further basal extension of infarct necrosis (Figure 1B). Percutaneous closure was planned, as a third sternotomy could preclude future transplantation listing.
Shunt run demonstrated elevated RA pressures, with a-wave 24 mm Hg and v-wave 28 mm Hg. Shunt size was estimated at 4.57 l/min (Qp/Qs 1.72). With a retrograde transfemoral approach and directed by an internal mammary catheter, a coated guidewire was advanced through the defect into the RA, where it was snared and externalized through the internal jugular vein (Figure 1C). A delivery sheath was advanced over the guidewire from the neck into the LV and ascending aorta (Figure 1D), and a 14-mm Amplatzer atrial septal occluder (St. Jude Medical, St. Paul, Minnesota) was successfully deployed with minimal residual shunting (Figures 1E to 1G) and an immediate 4-mm Hg improvement in mean RA and right ventricular pressures. Shunt size was reduced to 2.18 l/min (Qp/Qs 1.37) with residual shunting through the device itself, which was expected to improve with endothelialization. Tricuspid valve leaflets were free from impingement after device deployment as assessed by transesophageal echocardiogram with no significant regurgitation. The patient was successfully discharged and was stable at 2-month follow-up.
Acquired Gerbode defects are rare, and percutaneous closure has only previously been described in 3 cases of surgically acquired defects (1–3) but not after myocardial infarction. In this case, successful percutaneous closure allowed for immediate hemodynamic and clinical stabilization and the avoidance of a third sternotomy, which may have excluded the option of cardiac transplantation in the future.
Dr. Kar has received grant support and/or proctor/consulting fees from Abbott Vascular, Boston Scientific, and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 28, 2015.
- Revision received June 25, 2015.
- Accepted July 2, 2015.
- American College of Cardiology Foundation
- Fanari Z.,
- Barekatain A.,
- Abraham N.,
- Hopkins J.T.