Author + information
- Received July 19, 2016
- Revision received August 15, 2016
- Accepted August 25, 2016
- Published online November 14, 2016.
- Eduardo A. Arias, MD,
- Amit Bhan, MD,
- Zhan Y. Lim, MD and
- Michael Mullen, MD∗ ()
- Structural Heart Interventions Department, Barts Heart Centre, West Smithfield, London, United Kingdom
- ↵∗Reprint requests and correspondence:
Dr. Michael Mullen, Lead for Structural Heart Interventions Department, Barts Heart Centre, West Smithfield, London EC1A 7BE, United Kingdom.
We present 2 examples of post-myocardial infarction ventricular septal defect (PMIVSD) successfully treated by percutaneous closure using the Gore septal occluder (GSO) (W. L. Gore and Associates, Flagstaff, Arizona).
A 71-year-old woman was transferred to our institution after elective percutaneous intervention to the left anterior descending artery, complicated by coronary dissection and a periprocedural myocardial infarction. Two days later, a new pansystolic murmur was detected and echocardiography confirmed an apical PMIVSD. With incipient multiorgan failure, she underwent successful percutaneous closure of the defect using a 30-mm GSO on day 10 post-myocardial infarction.
A 79-year-old woman with a late presentation anterior myocardial infarction and PMIVSD underwent surgical repair with a bovine pericardial patch and bypass grafting. Post-operative echocardiography revealed 2 large separate residual PMIVSDs. Twenty-two days after surgery, she underwent percutaneous closure.
In both examples, procedural access was via the right internal jugular vein and right femoral artery. Left ventriculography showed severe left-to-right shunt. Standard percutaneous techniques, including crossing of the defect retrogradely and arteriovenous circuit formation were performed (1). Transoesophageal echocardiography and fluoroscopy were used for guidance.
In the first example, a 30-mm GSO was deployed and control angiogram showed a second separate apical defect with a mild to moderate shunt. After the procedure, liver and renal function normalized and the patient was discharged with a plan for elective surgery (Figure 1, Online Video 1). In the second example two 30-mm GSO devices were deployed in the inferior and posterior aspects of the septum surrounding the bovine pericardial patch. A control angiogram showed no residual shunt and the patient was discharged 5 days later (Figure 2, Online Video 2). Post-procedure, a gated computed tomography scan showed devices in situ with excellent conformation to the ventricular chambers (Figures 3 and 4). In both examples, an immediate hemodynamic improvement was noted.
Closure by PMIVSD is a complex procedure and technical challenges include unstable septal anatomy and a huge variation in size and shape of the defects. Early after the insult, the myocardium remains friable and in some cases stiffer devices could potentially extend the defect. In addition, we decided to use this device for the following reasons: 1) presence of slit-like defect at the infarct borders; 2) soft and compliant discs that could mold to the shape of the LV; and 3) a small waist so there was less chance of stretching the defect further. To the best of our knowledge, the information presented herein demonstrates the first successful use of the GSO to close PMIVSDs (2).
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 19, 2016.
- Revision received August 15, 2016.
- Accepted August 25, 2016.
- American College of Cardiology Foundation