Transcatheter closure of ventricular septal rupture with prolonged support of intra-aortic balloon pump after primary PCI: a case report

Abstract

Background Ventricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases. Case presentation A 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2–3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction. Conclusions Prolonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.

Post-Infarction Ventricular Septal Defect

“…If possible, waiting for a short period after the diagnosis will improve the tissue quality and allow the margins of the infracted muscle to develop a firmer scar, which can facilitate successful surgical VSD closure, thus preventing residual VSD. 4 , 22 , 31 However, some studies have reported a better survival after immediate surgical intervention. 2 , 22 , 28 , 29 …”

“…If possible, waiting for a short period after the diagnosis will improve the tissue quality and allow the margins of the infracted muscle to develop a firmer scar, which can facilitate successful surgical VSD closure, thus preventing residual VSD. 4,22,31 However, some studies have reported a better survival after immediate surgical intervention. 2,22,28,29 Current guidelines by both the American College of Cardiology-American Heart Association and European Society of Cardiology recommend immediate intervention in patients with post-MI VSD, irrespective of the clinical condition.…”

Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report

“…The current guidelines suggested early surgical repair as an urgent treatment [ 8 , 12 ]. However, delayed surgical strategy may be considered in patients who respond well to heart failure therapy, allowing infarcted tissue maturation for better surgical outcomes [ 8 , 13 ]. Preoperative optimization of the already poor cardiac function and hemodynamic status during the deferred period is a serious challenge [ 14 ].…”