Transcatheter treatment of postinfarct ventricular septal defects

Abstract

Postinfarct ventricular septal defects (VSDs) are a mechanical complication of acute myocardial infarction (AMI) with a very poor prognosis. They are estimated to occur in 0.2% of patients presenting with AMI, with 1-month survival of 6% without intervention. Guidelines recommend surgical repair, but recent advances in transcatheter technology, and bespoke device development, mean it is increasingly viable as a closure option. Surgical mortality is between 30% and 50% for all-comers, while in series of transcatheter closure, mortality was 32%. Transcatheter closure appears durable, with no evidence of late leaks and low long-term mortality in series with up to 5-year follow-up. Guidelines recommend early closure, which is likely to provide most benefit for patients regardless of the closure method. Multimodality cardiac imaging including echocardiography, CT and cardiac MRI can define size, shape, location of defects and their relationship to other cardiac structures, assisting with treatment decisions. Brief delay to allow stabilisation of the patient is appropriate, but untreated patients risk rapid deterioration. Mechanical circulatory support may be helpful, although the preferred modality is unclear. Transcatheter closure involves large bore venous access and the formation of an arteriovenous loop (under fluoroscopic and trans-oesophageal echocardiographic guidance) in order to facilitate deployment of the device in the defect and close the postinfarct VSD. Guidelines suggest transcatheter closure as an alternative to surgical repair in centres where appropriate expertise exists, but decisions for all patients with postinfarct VSD should be led by the multidisciplinary heart team.

Post-infarction ventricular septal rupture

“…In addition, these operations are difficult and likely cannot be mastered by most surgeons largely due to its rarity. Thus, in order to improve the outcomes of post-infarction VSD, patients should be referred to centers where both surgical and catheter-based techniques expertise are available (19,20). I firmly believe that patients with post-infarction VSD should be operated on as soon as the diagnosis is made to prevent worsening of the clinical presentation.…”

Przypadek kliniczny pacjenta z niedokrweinnym ubytkiem w przegrodzie międzykomorowej. Czy istnieje możliwość wyjścia z tego impasu?

“…Owing to bidirectional heart damage affected by AMI and sudden-onset cardiac shunt [5], patients with post--infarct VSD are likely to be haemodynamically compromised.…”

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

“…The patient had already completed reperfusion therapy and was under DAPT, thus transcatheter closure is an effective option in the timing of stable hemodynamics [ 26 , 27 ], but the DAPT is not a contraindication of surgical repair. Surgical repair was once considered but abandoned because of a higher risk of general anesthesia, extracorporeal circulation support, and bleeding when DAPT was adopted.…”

“…Surgical repair was once considered but abandoned because of a higher risk of general anesthesia, extracorporeal circulation support, and bleeding when DAPT was adopted. Absence of scientific head-to-head comparison, what is the first choice for VSR patients, surgical repair or percutaneous closure, remains a question for all cardiological professionals [ 26 ]. Here are the pros and cons we summarize about surgical and percutaneous operation of VSR.…”

“…The pros of percutaneous closure are minimal invasion and only local anesthesia needed. The cons of percutaneous closure are fluorescent exposure, shorter history of implementation, and occurrence of residual shunt, hemolysis, and device dislocation and/or embolism due to the irregular shape of VSR, which are the pitfalls and risks of previous transcatheter closures reported [ 7 , 26 , 28 ]. For this patient, the myocardium was still fragile, and a conventional guidewire and catheter operation through the rupture can induce malignant arrhythmia endangering the patient’s life.…”