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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 29  |  Issue : 1  |  Page : 17-19

Ventricular Septal Defect Complicating Inferior Acute Myocardial Infarction: A Case of Percutaneous Closure


1 Heart Department, University Hospital “S.Giovanni di Dio e Ruggi D'Aragona”, Salerno, Italy
2 Pediatric Cardiology and GUCH Unit, Fondazione Toscana CNR -G.Monasterio, Massa, Italy

Date of Web Publication20-Mar-2019

Correspondence Address:
Rodolfo Citro
Department of Heart, University Hospital “San Giovanni di Dio e Ruggi d'Aragona,” Heart Tower, Room 810, Largo Città di Ippocrate, Salerno 84131
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_60_18

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  Abstract 


Ventricular septal defect (VSD) is one of the most serious mechanical complications of acute myocardial infarction (AMI). Despite the incidence of post-AMI VSD in reperfusion era has reduced from 1%–2% to 0.17%–0.31%, it is a still life-threatening condition with poor prognosis. Surgical VSD closure is considered the best treatment approach since conservative management carries an extremely high mortality rate. Over the last decade, percutaneous transcatheter closure has emerged as an alternative therapeutic strategy for a patient with post-AMI VSD, with outcomes similar to cardiac surgery (30-day mortality 14%–66%). We present a case of inferior AMI complicated by posterobasal VSD and cardiogenic shock successfully treated with percutaneous closure. The role of echocardiography in diagnosis, management, and percutaneous procedure guiding has been emphasized.

Keywords: Acute myocardial infarction, echocardiography, percutaneous closure, ventricular septal defect


How to cite this article:
Ferraioli D, Santoro G, Bellino M, Citro R. Ventricular Septal Defect Complicating Inferior Acute Myocardial Infarction: A Case of Percutaneous Closure. J Cardiovasc Echography 2019;29:17-9

How to cite this URL:
Ferraioli D, Santoro G, Bellino M, Citro R. Ventricular Septal Defect Complicating Inferior Acute Myocardial Infarction: A Case of Percutaneous Closure. J Cardiovasc Echography [serial online] 2019 [cited 2019 Jun 20];29:17-9. Available from: http://www.jcecho.org/text.asp?2019/29/1/17/254597




  Introduction Top


Ventricular septal defect (VSD) is one of the most serious mechanical complications of acute myocardial infarction (AMI), leading to acute heart failure, cardiogenic shock (CS), and high mortality rate. The incidence has reduced in reperfusion era (0.17%–0.31%), but it remains a life-threatening event. Surgical repair was considered the only definitive treatment.[1] Over the last decade, percutaneous closure (PC) has emerged as an alternative strategy, with results similar to cardiac surgery. Echocardiography (Echo) plays an essential role for diagnosis, in guiding percutaneous procedures and follow-up. We present a case of ST-elevated inferior AMI, complicated by posterobasal VSD successfully treated with transcatheter closure.


  Case Report Top


An 85-year-old woman was hospitalized for chest pain occurred 10 h before during the night time. She had a history of diabetes, without any other cardiovascular risk factors. Clinical examination revealed arrhythmic heart sounds and clear lungs. Blood pressure was 100/60 mmHg. Convex upward ST-segment elevation with pathological Q-waves in inferior leads and atrial fibrillation were detected on ECG. Troponin I (39.6 ng/ml; normal value [n.v.] 0–0.10) and myoglobin (733.7 ng/ml; n.v. 10–92) levels were increased. Akinesia of basal segments of the inferior wall and of posterior interventricular septum, with preserved left ventricle (LV) ejection fraction, was found by transthoracic echocardiogram (TTE). Conversely, right ventricle (RV) was dilated with severe systolic dysfunction (tricuspid annular plane systolic excursion = 4 mm). Inferior AMI with RV involvement was diagnosed. The patient underwent emergency coronary angiography, which revealed total occlusion of the mid right coronary artery, treated by balloon angioplasty and drug-eluting stent, and a chronic total occlusion of left anterior descending coronary artery. During the 2nd hospital day, the patient became hypotensive and a new holosystolic murmur with large irradiation was heard. A fast worsening of the hemodynamic condition leading to CS required inotropic agents' administration. A bedside Echo revealed a posterobasal VSD, measuring 12 mm × 9 mm on three-dimensional (3D) echo, with left-to-right shunting, and pulmonary hypertension (pulmonary artery systolic pressure [PASP] = 60 mmHg) [Figure 1]a, [Figure 1]b, [Figure 1]c. The case was analyzed by the heart team. Owing to the advanced age, hemodynamic instability, and high surgical risk, the patient was scheduled for transcatheter VSD closure. The procedure was performed 7 days after AMI onset, under both fluoroscopic and transesophageal echocardiographic (TEE) guide, without the use of the LV assistance devices. Through the jugular vein, a 26-mm Amplatzer atrial septal occluder on the delivery sheath was advanced via RV into the VSD [Figure 2]a and [Figure 2]b. A partial occlusion of VSD with a significant reduction of the ventricular shunt was obtained. Echocardiographic evaluation [Figure 3]a and [Figure 3]b performed 6 days later confirmed a correct apposition of the device with just trivial residual shunt and decreased PASP (30 mmHg). During the 2 weeks after procedure, the clinical status dramatically improved, thereby the patient being discharged in NYHA Class II. At 9 months follow-up, she was asymptomatic and clinically stable, with unchanged prosthetic gradients.
Figure 1: (a) Two-dimensional transthoracic apical four-chamber zoom view focusing the posterobasal ventricular septal defect. (b) Two-dimensional transthoracic apical four-chamber view on color Doppler shows the left-to-right shunt. (c) Three-dimensional transthoracic apical four-chamber view images show ventricular septal defect and allow its sizing

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Figure 2: Fluoroscopic images before (a) and after (b) implantation of a 26-mm Amplatzer atrial septal occluder

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Figure 3: Two-dimensional transthoracic apical four-chamber view images acquired 6 days after percutaneous closure: a 26-mm Amplatzer atrial septal occluder correctly placed (a) and mild residual interventricular shunt on color Doppler (b)

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  Discussion Top


VSD is a rare but life-threatening condition, leading to hemodynamic instability and CS. Its incidence decreased from 1–2% in prethrombolytic era[2] to 0.17–0.31% of all AMIs[1],[2] during the last decades. This reduction seems to be related to the improvement of coronary reperfusion therapies, however the prognosis of this complication remains poor.

VSD generally develops about 3–5 days after AMI onset. This interval has decreased in reperfusion era.[2]

Many risk factors are described in literature, as female sex, advanced age, and systemic hypertension.[2]

VSD has been more often observed in patients with total occlusion of the infarct-related artery and minimal collaterals, generally in a context of single-vessel disease, after anterior AMI.[2]

Furthermore, VSD has been described associated with inferior AMI: In this case, it is often complex (multiple, irregular), located in the inferobasal portion of the septum, difficult to approach surgically, and associated with worse prognosis.[2]

RV dysfunction, development of CS, and early surgery have been reported as significant independent predictors of mortality.[1] In a series of 29 patients with post-AMI VSD and CS underwent percutaneous occlusion, Thiele et al. reported a 30-day mortality of 86%.[3]

2D TTE, widely available even in intensive care unit, enables the first diagnostic approach. It can underestimate VSD features. Real-time (RT) 3D TTE and TEE provide more accurate definition of: (1) VSD site, dimensions, and relation with surrounding myocardial wall, (2) shunt amount, and (3) ventricular function. Especially 3D RT TEE is necessary during PC, in guiding the device delivery orientation, and in the postoperative assessment of device proper placement, optimal occluder expansion, and residual shunt.[4],[5]

Treatment options include conservative management, with mortality rate approaching 95%, and invasive strategy.[2] Endocardial patch is the conventional surgical procedure.[1] Both STEMI ESC guidelines[6] and ACC/AHA guidelines[7] recommend an emergency or early surgical intervention. However, several studies suggest to delay surgery: Serpytis et al.[8] reported 100% survival rate in patients surgically treated after 3–4 weeks of stabilization versus 100% mortality in patients having surgery within 10 days from symptoms onset.

Usually, PC is reserved to high surgical risk patients and to complex VSD, with inferior-basal location due to a more favorable access from the upper jugular vein.[1] It is also advised in unstable patients as a bridge to later and safer surgical approach. Moreover, PC has been used IN hybrid approach, as in case of VSD extension or recurrence, partial patch detachment after primary surgical repair, or in case of dislodgement or embolization of the occluding device.[1] However, PC has also been described as successful definitive treatment,[9],[10] with similar outcomes with respect to cardiac surgery (30-day operative mortality 27%–65% vs. 14%–66% after PC).[1] Several technical challenges have been reported such as friable edge that results in difficult device stabilization and increase embolization risk; necrosis progression, causing difficult selection of device size; proximity to atrioventricular valves and serpiginous defect course, leading to complex procedure steps.[9],[10] However, PC results in sudden shunt reduction and hemodynamic stabilization. Owing to the use of more tailored devices and the technology progress, PC of VSD has been emerged as a valid cost-effective alternative to surgery and should be advised, particularly in critical patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cinq-Mars A, Voisine P, Dagenais F, Charbonneau É, Jacques F, Kalavrouziotis D, et al. Risk factors of mortality after surgical correction of ventricular septal defect following myocardial infarction: Retrospective analysis and review of the literature. Int J Cardiol 2016;206:27-36.  Back to cited text no. 1
    
2.
Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global utilization of streptokinase and TPA for occluded coronary arteries) trial investigators. Circulation 2000;101:27-32.  Back to cited text no. 2
    
3.
Thiele H, Kaulfersch C, Daehnert I, Schoenauer M, Eitel I, Borger M, et al. Immediate primary transcatheter closure of postinfarction ventricular septal defects. Eur Heart J 2009;30:81-8.  Back to cited text no. 3
    
4.
Scandura S, Ussia GP, Caggegi A, Cammalleri V, Millan G, Tamburino C, et al. Postinfarction ventricular septal defect: The role of three-dimensional echocardiography. Echocardiography 2012;29:E107-9.  Back to cited text no. 4
    
5.
Pace G, Filippone G, Corrado E, Triolo F, Argano V, Novo S, et al. Echocardiographic assessment of ventricular septal rupture and left ventricular aneurysm after inferior and posterior myocardial infarction. J Cardiovasc Echogr 2018;28:61-4.  Back to cited text no. 5
    
6.
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the european society of cardiology (ESC). Eur Heart J 2018;39:119-77.  Back to cited text no. 6
    
7.
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, De Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2013;61:e78.  Back to cited text no. 7
    
8.
Serpytis P, Karvelyte N, Serpytis R, Kalinauskas G, Rucinskas K, Samalavicius R, et al. Post-infarction ventricular septal defect: Risk factors and early outcomes. Hellenic J Cardiol 2015;56:66-71.  Back to cited text no. 8
    
9.
Moscarella E, Santoro G, Gaio G, Palladino T, D'Aiello AF, Mahmoud HT, et al. Percutaneous treatment of complex post-myocardial infarction ventricular septal defect: Case report and literature review. G Ital Cardiol (Rome) 2017;18:159-63.  Back to cited text no. 9
    
10.
Capasso F, Caruso A, Valva G, Lonobile T, Grimaldi MG, Santoro G, et al. Device closure of 'complex' postinfarction ventricular septal defect. J Cardiovasc Med (Hagerstown) 2015;16 Suppl 1:S15-7.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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