Transcatheter closure of ventricular septal defect: a nonsurgical approach to the care of the patient with acute ventricular septal rupture.

Acute ventricular septal rupture is a potentially fatal complication of myocardial infarction. In the past, surgical repair was the only treatment option for this life-threatening event. However, not all patients are good surgical candidates. Transcatheter closure of a ventricular septal defect (VSD) with a prosthesis called the Rashkind Patent Ductus Arteriosis Occluder System allows closure of the VSD without the possible complications associated with open-heart surgery. This treatment has potential as a temporary measure for patients awaiting surgical repair of VSD. Transcatheter closure may also be used as a permanent treatment for those patients considered to be poor surgical candidates. This case presentation addresses the use of a state-of-the-art nonsurgical approach to VSD closure. The focus is on the unique medical and nursing interventions used in caring for the patient suffering from a myocardial infarction complicated with postinfarction ventricular septal defect.     

Combined catheter ventricular septal defect closure and multivessel coronary stenting to treat postmyocardial infarction ventricular septal defect and triple-vessel coronary artery disease: a case report.

Ventricular septal defect following acute myocardial infarction is a rare but life-threatening complication. Early surgical closure improves survival but carries a considerable risk. Percutaneous transcatheter closure is an alternative but experience to date is limited. We report a case of successful transcatheter closure of postmyocardial infarction ventricular septal defect (VSD) in a 55-year-old male with the Amplatzer muscular VSD occluder device and complete percutaneous revascularization with successful multivessel coronary stenting for three-vessel disease as a staged procedure. The technique and its potential use as an alternative to surgical approach for treatment of acute myocardial infarction and its complication (VSD) are discussed.     

Transcatheter closure of ischemic and post-traumatic ventricular septal ruptures.

Post-traumatic ventricular septal defects (VSD) can occur after acute MI or iatrogenically after invasive surgical procedures. Emergency surgery is associated with high perioperative mortality and postsurgical shunt in up to 20% of patients. Transcatheter closure (TCC) of post MI VSD may be an alternative that avoids the high risk of surgery. We report a lower mortality and morbidity than surgical closure in the post infarction VSD's even with a short interval between defect occurrence and percutaneous device placement. Furthermore, in patients with a failed or suboptimal surgical result adjunctive percutaneous closure may be beneficial and offers an alternative to redo VSD repair. Finally, in patients who suffer an unexpected traumatic VSD post surgical procedure, percutaneous closure offers an alternative with excellent results.     

Outcomes of Early Versus Delayed Transcatheter Closure of Post-Myocardial Infarction Ventricular Septal Defect

BackgroundPost myocardial infarction ventricular septal defect (VSD) is a rare, but devastating complication which carries a poor prognosis if left untreated. Optimal therapy remains unclear and surgical repair is associated with high mortality.ObjectiveThe aim of our study is to compare 30-day survival in patients with early versus late primary transcatheter repair of post myocardial infarction ventricular septal defect.MethodsWe performed a comprehensive search of published data through SCOPUS and identified published reports of primary transcatheter closure of post myocardial infarction VSD. We included case reports and series that reported timing of VSD closure and 30-day survival and excluded those with prior surgical repair. Early repair was defined as transcatheter closure within 14 days of diagnosis of VSD while late repair was defined as transcatheter closure after 14 days of diagnosis of VSD.ResultsA total 27 publications describing 193 patients were identified in the SCOPUS search. We excluded 8 publications with no reported timing of VSD repair or 30-day outcome. Of the 193 patients initially included, a total of 126 patients fulfilled all the criteria and were included in the final analysis. The overall 30-day survival rate was found to be 62.7% (79 patients). In the early repair group, only 36.2% of the patients were still alive at 30 days compared to 85.3% in the delayed repair group, P < .01. No significant difference in age, gender, presence of shock, VSD size, presence of significant residual shunt, location of VSD or infarction was observed. The early repair group was found to have a significantly larger Qp: Qs ratio as well as larger occluder size and lower rate of successful repair.ConclusionCompared to the late repair group, the early transcatheter VSD repair group had a larger pre-procedure Qp:Qs and worse 30-day survival. Further studies are needed to determine the optimal timing of transcatheter repair of a post myocardial infarction VSD.     

Transcatheter closure of a complex postmyocardial infarction ventricular septal defect after surgical patch dehiscence

Ventricular septal defect (VSD) complicating acute myocardial infarction is a rare but serious event carrying a high mortality. Residual shunting after emergency surgical repair is common, adversely affects prognosis and can necessitate reoperation. We describe the successful transcatheter VSD closure with the Amplatzer occluder in a 75-year old man after earlier emergency surgical repair of a VSD complicating an acute myocardial infarction. The technique and positioning of the device in a tortuous infero-apical VSD are described.     

Transcatheter closure of a ventricular septal defect following myectomy for hypertrophic obstructive cardiomyopathy

Post-operative ventricular septal defect (VSD) following septal myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM) is a rare complication which may warrant closure. Repeat early sternotomy for surgical closure of the VSD seems undesirable and transcatheter VSD closure may be a valid alternative. We report the case of successful closure of a 10-mm VSD following surgical therapy for HOCM using an Amplatzer Muscular VSD Occluder.     

Transcatheter closure of recurrent postmyocardial infarction ventricular septal defects utilizing the Amplatzer postinfarction VSD device: a case series.

The initial therapy for postmyocardial infarction ventricular septal defects is surgical repair of the defect. Unfortunately, a significant number of patients develop recurrent ventricular septal defects (VSDs) following operative repair. Transcatheter closure offers an alternative to reoperation in these critically ill patients. We present a series of four patients in whom recurrent ventricular septal defects were closed using an Amplatzer VSD device.     

Immediate primary transcatheter closure of postinfarction ventricular septal defects

Aims: Immediate surgical repair of ventricular septal defect (VSD)complicating acute myocardial infarction is associated withhigh mortality. Percutaneous device closure appears to be safeand effective in patients treated for a residual shunt afterinitial surgical closure, as well as in patients with a chronicpost-infarct VSD. Primary transcatheter VSD closure in the acutesetting may also offer advantages over surgery. Methods and results: Between September 2003 and February 2008, 29 consecutive patientsunderwent primary transcatheter VSD closure. Clinical, procedural,and outcome data were collected. Patients were divided intothose with and those without cardiogenic shock at presentationfor risk stratification. The median follow-up time of survivingpatients was 730 days. The median time between VSD occurrenceand closure was 1 day [interquartile range (IQR) 1–3]and the initial procedural success rate was 86%. The shunt (Qp:Qs)could be reduced from 3.3 (IQR 2.3–3.8) to 1.4 (IQR 1.2–1.7;P < 0.001). Procedure-related complications such as majorresidual shunting, left ventricular rupture, and device embolizationoccurred in 41%. The overall 30-day survival rate was 35%. Mortalitywas higher for cardiogenic shock in comparison to non-shockpatients (88 vs. 38%, P < 0.001). Conclusion: Interventional acute VSD closure is a promising technique thatcan be performed with a high procedural success rate and mayoffer an alternative to surgery. Despite the less invasive technique,mortality of postinfarction VSD remains high, particularly inpatients with cardiogenic shock. Further developments in devicesand delivery techniques are required.     

Percutaneous closure of perimembranous ventricular septal defects with Amplatzer occluders--a single centre experience

BACKGROUND: Perimembranous ventricular septal defect (VSD) is the most common congenital heart defect. Percutaneous transcatheter closure of VSD is one of the greatest challenges in interventional cardiology. AIM: Presentation of our experience in transcatheter closure of perimembranous VSD. METHODS: Eighteen patients were treated. Nine patients (group I) had VSD closed with implant Amplatzer Perimembranous VSD Occluder (PMVSDO) whereas the other nine had VSD closed with Muscular VSD Occluder (MVSDO). In the second group the presence of at least 4 mm rim from aortic valve was mandatory to undergo the procedure. Average patients age was 17.1 (3.2-40) years, defect diameter--4.7 (4-8) mm and Qp/Qs ratio--1.84 (1.5-4.6). Perimembranous interventricular septum aneurysm was noted in 5 cases. Only patients who had hemodynamically important defect (Qp/Qs ratio >1.5) were selected for interventional VSD closure. Patients with subarterial VSDs, pulmonary hypertension or/and aortic regurgitation were excluded. Ventricular septal defect closure was performed with standard techniques. RESULTS: Procedures were completed successfully in 16 of 18 patients. There was no early or late implant embolisation. After the procedure in every case complete closure or important reduction of the shunt was observed. In the group I there was a trend towards more frequent occurrence of rhythm disturbances (p=0,08), including two cases with severe arrhythmias occurring during VSD closure requiring abandoning of procedure. In other 2 cases (patients age 12 and 14 years) in the second week after PMVSDO placement complete atrio-ventricular block occurred. In one patient sinus rhythm was restored after steroid treatment whereas another patient required pacemaker implantation. In group II mild nonprogressive tricuspid regurgitation was noted in 3 patients. CONCLUSIONS: Percutaneous perimembranous VSD closure is an interesting alternative to surgical treatment. In selected cases closure of the defect with muscular VSD implant is effective and safe.     

Outcomes of Transcatheter Closure in Outlet-Type Ventricular Septal Defect after 1 Year

Background: Ventricular septal defect (VSD) is the most common congenital heart disease. Transcatheter VSD closure is an effective treatment for patients with muscular and perimembranous VSD. However, there is a limit data for outlet VSD, especially impact to the aortic valve leaflet after transcatheter closure. This study aims to assess the outcomes of transcatheter closure of the outlet-type ventricular septal defect (OVSD) after 1 postoperative year. Methods: A retrospective study was performed including 50 patients who underwent transcatheter (n = 25) and surgical (n = 25) OVSD closure during the exact time frame at two medical centres. Results: The median age and body weight of patients in the transcatheter group were significantly higher than those of patients in the surgical group (7.0 vs. 2.8 years; 27.0 vs. 11.4 kg; p < 0.01). The defect size in the surgical group was significantly larger than that in the transcatheter group (5.0 vs. 3.0 mm; p < 0.01). All OVSD patients have successful transcatheter closure (100%) as effective as surgical closure. Less than small residual shunt was present 20% and 8% immediately after the procedure in the transcatheter and surgical groups (p = 0.50), which decreased to 12% and 4% at the 1-year follow-up (p = 0.61), respectively. No incidence of complete atrioventricular block and other complications was observed in both groups, and no significant differences were noted in the new onset or worsening of the aortic regurgitation in both groups (p = 1.0). Conclusions: Transcatheter treatment could be effectively and safely achieved for OVSD closure at 1-year follow-up.     

Percutaneous closure of postoperative ventricular septal defects with the Amplatzer device.

The objective of this study was to look at the procedure, the results, and the follow-up of patients who underwent percutaneous closure of a residual ventricular septal defect (VSD) following a surgical closure using the Amplatzer VSD device. Four patients had an original diagnosis of tetralogy of Fallot, two patients had a patch leak following a surgical repair of a VSD, and three patients had a VSD not repaired at the time of surgery. All patients fulfilled the currently accepted surgical criterion for reoperation (Qp/Qs>1.5). The mean Qp/Qs was 1.8+/-0.3 (1.5-2.3). Four patients underwent VSD closure using an Amplatzer perimembranous VSD device and in five patients an Amplatzer muscular VSD device was implanted. We performed percutaneous closure in nine patients. The size of the residual shunt ranged from 6 to 14 mm and the size of device used ranged from 8 to 16 mm. The arteriovenous loop needed to be recreated in two patients because of failure to advance the delivery sheath. There was complete closure of the defect in six cases, and a small residual shunt remained in three cases. Percutaneous closure of postoperative VSDs appears to be an effective way to resolve a hemodynamically significant residual shunt. There were no difficulties encountered with implantation of the devices. These promising short-term results need reinforcement with additional long-term data.     

Unplanned staged hybrid management of postmyocardial infarction ventricular septal defect

Ventricular septal defect (VSD) is an uncommon but potentially deadly complication of transmural myocardial infarction (MI). Emergency surgical treatment has traditionally offered the best chance for survival. However, operative intervention is associated with high mortality and can be complicated by a recurrent VSD due to tissue friability around the infarcted area. Percutaneous catheter-based closure techniques can be used to treat these critically ill patients, offering a less invasive and less morbid technique. This case demonstrates the successful application of an unplanned, staged hybrid approach utilizing initial percutaneous and subsequent surgical repair after recovery of tissue integrity.     

Ventricular septal defect and left ventricular aneurysm: late occurrence as complications of an acute myocardial infarction

Mechanical complications of acute myocardial infarction (AMI) such as a ventricular septal defect (VSD) usually occur within the first week. In the thrombolytic era, the incidence of a VSD has not increased, but has been reported to occur earlier than previously described. We report an unusual case of an elderly Caucasian female with an acute anterior wall myocardial infarction treated with thrombolytic therapy. Her AMI was complicated by pulmonary edema secondary to a VSD and a left ventricular aneurysm five weeks later. Prompt diagnosis, immediate surgical closure of the VSD, and aneurysmectomy resulted in her complete recovery.     

Complicated transcatheter closure of postinfarction ventricular acute septal defect

The ventricular septal rupture is an uncommon complication of myocardial infarction (MI) with a reported incidence of 0.2% in the thrombolytic era. The outcome remains extremely poor, and surgical defect closure still remains the only therapeutic option improving survival. There are single reports based on a small series of case reports about transcatheter closure of postinfarction ventricular septal defects (VSD) and experience is limited. We present a case of a 71-year-old man with a posteroinferior MI complicated by a ventricular septal rupture with 24 mm width. Due to the severity of the case, surgical approach was denied; we attempted transcatheter closure of the defect in a lifesaving situation. The VSD was partially closed with a 26 mm Amplatzer? septal occluder (AGA Medical Corp., Plymouth, Minnesota) without adequate expansion of the right disc, due the complexity of the tract. The patient died one day after the procedure.     

Retrograde Percutaneous Closure of a Ventricular Septal Defect after Myectomy for Hypertrophic Obstructive Cardiomyopathy

In patients with hypertrophic obstructive cardiomyopathy, hemodynamically significant ventricular septal defect after septal myectomy is a rare sequela that warrants closure. Percutaneous closure provides a safer alternative to repeated sternotomy, which is associated with significant morbidity and mortality rates. We report a possibly unique case of successful retrograde percutaneous closure, with an AMPLATZER Muscular VSD Occluder, of an iatrogenic ventricular septal defect consequent to surgical therapy for hypertrophic obstructive cardiomyopathy.Key words: Cardiac catheterization/methods, cardiomyopathy, hypertrophic/therapy, heart septal defects, ventricular/therapy, iatrogenic disease, myectomy, postoperative complications, prosthesis implantation/methods, septal occluder device, ventricular septal defectPatients with hypertrophic obstructive cardiomyopathy (HOCM) are candidates for surgical myectomy or ethanol ablation if, despite medical therapy, they remain symptomatic with New York Heart Association functional class III disease and severe left ventricular outflow tract (LVOT) gradients.¹ A rare sequela of myectomy via the Morrow procedure is iatrogenic ventricular septal defect (VSD). Although surgical closure remains the mainstay of treatment for most VSDs, treatment of clinically significant postoperative residual VSDs remains a challenge. Percutaneous closure provides a safer alternative to reoperation.^2,3 We report a possibly unique case of successful retrograde percutaneous closure of an iatrogenic VSD, consequent to surgical therapy for HOCM, by means of an AMPLATZER® Muscular VSD Occluder (St. Jude Medical, Inc.; St. Paul, Minn).     

Post-infarction ventricular septal defect: Percutaneous transvenous temporary closure using a Swan-Ganz catheter

We report on a case of temporary closure of a post-infarction ventricular septal defect (VSD) using a Swan-Ganz catheter through a femoral transvenous approach. This resulted in substantial improvement in the hemodynamic status of the patient. Six hr later, the patient underwent surgery for VSD closure. When immediate surgical intervention is not possible, it may be helpful to stabilize the patient until surgery can be performed. Thus, such a treatment has potential as a temporary measure for patients awaiting surgical repair of post-infarction VSD. Cathet. Cardiovasc. Intervent. 47:208–210, 1999. © 1999 Wiley-Liss, Inc.     

Surgical treatment of ventricular septal defect in the first year of life]

Forty six infants with a large ventricular septal defect (VSD) underwent surgical treatment during the first 12 months of life. Forty three patients ranging in age from 3 to 12 months (mean age 10.4 months) and weighting from 3.0 to 8.2 kg (mean weight 6.8 kg) had primary surgical closure of their VSD. All infants were below the third percentile for weight preoperatively. In 40 patients (93%) the defect was closed through the right atrium. Three patients (7.0%) died in the early postoperative period. Surgically induced heart block occurred in one patient (2.3%). Late results were assessed in 29 surgical survivors (mean follow-up 26 months). There was no late mortality. Relief of congestive heart failure was prompt in all patients following closure of VSD. Right bundle branch block with left anterior hemiblock developed in 5 patients (17.2%), and right bundle branch block alone in 10 patients (34.5%). Three patients (mean age 4.3 months, mean weight 2.7 kg) underwent initial palliative pulmonary artery banding (PAB). There were no operative or late mortality. Closure of VSD and pulmonary artery debanding was performed in two of these patients, with no mortality. Prior to intracardiac correction the pulmonary artery pressure distal to the band was normal; no band related complications were found. Early primary closure is the treatment of choice for symptomatic infants with large VSDs. In particular circumstances, however, PAB may provide effective palliation.     

"Acquired" subvalvular aortic stenosis after repair of a ventricular septal defect.

Of 353 children who underwent surgical repair of a congenital heart defect, including closure of a ventricular septal defect (VSD), 12 patients (four with tetralogy of Fallot, five with a VSD, and three with a double-outlet right ventricle) developed subaortic stenosis, which was diagnosed one to six years after the surgical procedure. Five patients required surgical treatment of the subaortic stenosis, and one required percutaneous balloon angioplasty. Postsurgical subaortic stenosis appears to be an uncommon progressive acquired disease.     

Ventricular septal defect following blunt trauma: spontaneous closure of residual defect after surgical repair

As a result of blunt chest trauma a patient developed a large ventricular septal defect (VSD). After surgical closure of the defect a grade 2/6 systolic murmur persisted. One year later findings were the same and left ventriculogram revealed a small residual VSD. Two years after the operation the systolic murmur had disappeared. We postulate that gradual endothelialization and possibly small thrombi (formed around and over the Dacron patch graft) caused the defect to close. This case serves to illustrate some of the Dacron patch graft) caused the defect to close. This case serves to illustrate some of the complexities in the diagnosis and management of an acquired VSD. To our knowledge this is the first reported spontaneous closure of a VSD occurring after incomplete surgical repair.     

Quantitation of echocardiographic predictors of outcome in infants with isolated ventricular septal defect

Clinical and morphometric features such as ventricular septal defect (VSD) size and location may determine outcome in infants with an isolated VSD. However, no currently available data allow quantitative estimation of the probability of spontaneous closure or surgery in individual patients. To identify independent predictors of outcome and to quantitate the probability of spontaneous closure and surgery in patients with isolated VSD, we studied 156 consecutive infants who had a diagnosis of an isolated VSD between January 1, 1988, and December 31, 1990, and who were subsequently monitored for 28.5 ± 15 months. Of the 149 patients with membranous (n = 100) and muscular (n = 49) defects who were studied, 46 (31%) patients had spontaneous closure, and an additional 37 (25%) patients underwent surgical repair. Univariate analysis identified defect cross-sectional area indexed to body surface area, location in the muscular septum, presence of Down syndrome, and in membranous defects the presence of aneurysmal tissue as potential predictors of spontaneous closure or surgery. Multiple logistic regression analysis with these candidate variables identified indexed defect cross-sectional area as an independent predictor of spontaneous closure and surgery (p < 0.001). An inverse nonlinear relationship was seen between indexed VSD area and the probability of spontaneous closure (probability = (1 + e[−1.74 + 4.57CSA])⁻¹ and a positive nonlinear relationship between indexed VSD area and the probability of surgery (probability = (1 + e[3.39 − 2.31CSA])⁻¹). Muscular defects were more likely to close spontaneously than membranous defects (odds ratio 2.6, 95% CL = 1.01 − 6.8, p = 0.04). Aneurysmal tissue formation and presence of Down syndrome did not predict outcome after controlling for defect size. Thus echocardiographic measurement of VSD cross-sectional area enables quantitation of probability of spontaneous closure and surgery in individual infants with an isolated VSD.