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Transcatheter balloon closure of post-myocardial infarction ventricular septal defect: a bridge to surgery
International Journal of Cardiology 92 (2003) 325 – 326 www.elsevier.com/locate/ijcard
Letter to the Editor
Transcatheter balloon closure of post-myocardial infarction ventricular septal defect: a bridge to surgery Mario Zanchetta *, Luigi Pedon, Gianluca Rigatelli, Marco Zennaro, Pietro Maiolino Department of Cardiovascular Disease, Cittadella General Hospital, 35013 Padova, Italy Received 3 October 2002; accepted 7 January 2003
Management of ventricular septal defect (VSD) occurring within a few days of an infarct by medical therapy, surgical repair or transcatheter closure is difficult and too often unsuccessful [1,2] due to progressive multiorgan failure despite inotropic supports and continued maturation of the myocardial infarction over time. A 62-year-old woman was admitted within 6 h of symptom onset to our intensive care unit with the diagnosis of anterior wall myocardial infarction and was conservatively managed with enzymatic thrombolysis. She remained stable until the 8th post-infarction day when she developed a new pansystolic murmur and congestive heart failure. Transthoracic echocardiogram revealed anteroseptal akinesia and a disrupted midventricular septum with evidence of severe left-to-right shunt by color Doppler. Cardiac catheterization showed the location of the defect by angled angiographic view (Fig. 1A), a 2.5:1 left-to-right shunt, severe pulmonary artery hypertension (70/40 mmHg), raised wedge pressures (mean 24 mmHg), total occlusion of the mid left anterior descending coronary artery, 60% stenosis of the proximal right coronary artery, and ejection fraction of 40%. Given the decompensated condition despite the intravenous inotropic support, urgent transcatheter closure of post-infarction VSD was attempted, using the arteriovenous wire loop technique described by Lock et al. [3] (Fig. 1B). The estimated balloon stretched diameter of the defect was 22 mm, being too large to be closed by a percutaneous device. In agreement with cardiothoracic surgeons we contemplated an interim measure to provide short-term hemodynamic stabilization before surgery. A calibrated sizing balloon (Meditech, Boston Scientific, MA, USA) was inflated up to 25 mm in diameter with diluted contrast and pulled gently against the ventricular septum (Fig. 1C). Once adequate balloon placement was obtained, a repeated left ventricular angiography revealed no significant shunt (Fig. 1D), and the * Corresponding author. Tel.: +39-49-942-4557; fax: +39-49-942-4531. E-mail address: [email protected] (M. Zanchetta). 0167-5273/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(03)00116-5
patient showed noticeable hemodynamic improvement in the cardiac catheterization laboratory. The systemic blood pressure increased from 80/40 to 115/70 mmHg and the pulmonary artery pressure decreased to 40/20 mmHg. During the following days, the patient remained hemodynamically stable and weaned off high-dose dopamine successfully. Transthoracic echocardiogram was performed to
Fig. 1. Steps of post-infarction mid muscular ventricular septal defect closure with balloon catheter. (A) Long axial oblique left ventriculogram demonstrates a mid muscular ventricular septal defect (arrows). (B) The end of the 0.035W 260 cm angled guide wire (Terumo Corporation, Tokyo, Japan) is snared using a 10 mm Amplatz goose-neck snare (Microvena Corporation, White Bear Lake, MN, USA), forming an arteriovenous wire loop. (C) A calibrated sizing balloon (Meditech, Boston Scientific) is inflated up to 25 mm in diameter with diluted contrast and pulled gently against the ventricular septum. (D) Repeated long axial oblique left ventriculogram after balloon inflation shows complete closure of the defect.
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evaluate optimal balloon position and to exclude interference with adjacent atrioventricular valve structures. The 4th day after the procedure the patient underwent successful coronary artery bypass grafting and VSD repair. Even if more experience is needed to assess the value of balloon closure as a bridge to surgery in acute ventricular septal rupture, it seems reasonable to explore alternative approaches to VSD closure as a strategy for short-term hemodynamic stabilization and for myocardial strengthening by scarring before urgent surgery or permanent device placement.
References [1] Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Circulation 2000;101:27 – 32. [2] Waight DJ, Hijazi ZM. Post-myocardial infarction ventricular septal defect: a medical and surgical challenge. Catheter Cardiovasc Interv 2001;54:488 – 9. [3] Lock JE, Block PC, McKay RG, Baim DS, Keane JF. Transcatheter closure of ventricular septal defects. Circulation 1988;78:361 – 8.
Letter to the Editor
Transcatheter balloon closure of post-myocardial infarction ventricular septal defect: a bridge to surgery Mario Zanchetta *, Luigi Pedon, Gianluca Rigatelli, Marco Zennaro, Pietro Maiolino Department of Cardiovascular Disease, Cittadella General Hospital, 35013 Padova, Italy Received 3 October 2002; accepted 7 January 2003
Management of ventricular septal defect (VSD) occurring within a few days of an infarct by medical therapy, surgical repair or transcatheter closure is difficult and too often unsuccessful [1,2] due to progressive multiorgan failure despite inotropic supports and continued maturation of the myocardial infarction over time. A 62-year-old woman was admitted within 6 h of symptom onset to our intensive care unit with the diagnosis of anterior wall myocardial infarction and was conservatively managed with enzymatic thrombolysis. She remained stable until the 8th post-infarction day when she developed a new pansystolic murmur and congestive heart failure. Transthoracic echocardiogram revealed anteroseptal akinesia and a disrupted midventricular septum with evidence of severe left-to-right shunt by color Doppler. Cardiac catheterization showed the location of the defect by angled angiographic view (Fig. 1A), a 2.5:1 left-to-right shunt, severe pulmonary artery hypertension (70/40 mmHg), raised wedge pressures (mean 24 mmHg), total occlusion of the mid left anterior descending coronary artery, 60% stenosis of the proximal right coronary artery, and ejection fraction of 40%. Given the decompensated condition despite the intravenous inotropic support, urgent transcatheter closure of post-infarction VSD was attempted, using the arteriovenous wire loop technique described by Lock et al. [3] (Fig. 1B). The estimated balloon stretched diameter of the defect was 22 mm, being too large to be closed by a percutaneous device. In agreement with cardiothoracic surgeons we contemplated an interim measure to provide short-term hemodynamic stabilization before surgery. A calibrated sizing balloon (Meditech, Boston Scientific, MA, USA) was inflated up to 25 mm in diameter with diluted contrast and pulled gently against the ventricular septum (Fig. 1C). Once adequate balloon placement was obtained, a repeated left ventricular angiography revealed no significant shunt (Fig. 1D), and the * Corresponding author. Tel.: +39-49-942-4557; fax: +39-49-942-4531. E-mail address: [email protected] (M. Zanchetta). 0167-5273/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(03)00116-5
patient showed noticeable hemodynamic improvement in the cardiac catheterization laboratory. The systemic blood pressure increased from 80/40 to 115/70 mmHg and the pulmonary artery pressure decreased to 40/20 mmHg. During the following days, the patient remained hemodynamically stable and weaned off high-dose dopamine successfully. Transthoracic echocardiogram was performed to
Fig. 1. Steps of post-infarction mid muscular ventricular septal defect closure with balloon catheter. (A) Long axial oblique left ventriculogram demonstrates a mid muscular ventricular septal defect (arrows). (B) The end of the 0.035W 260 cm angled guide wire (Terumo Corporation, Tokyo, Japan) is snared using a 10 mm Amplatz goose-neck snare (Microvena Corporation, White Bear Lake, MN, USA), forming an arteriovenous wire loop. (C) A calibrated sizing balloon (Meditech, Boston Scientific) is inflated up to 25 mm in diameter with diluted contrast and pulled gently against the ventricular septum. (D) Repeated long axial oblique left ventriculogram after balloon inflation shows complete closure of the defect.
326
M. Zanchetta et al. / International Journal of Cardiology 92 (2003) 325–326
evaluate optimal balloon position and to exclude interference with adjacent atrioventricular valve structures. The 4th day after the procedure the patient underwent successful coronary artery bypass grafting and VSD repair. Even if more experience is needed to assess the value of balloon closure as a bridge to surgery in acute ventricular septal rupture, it seems reasonable to explore alternative approaches to VSD closure as a strategy for short-term hemodynamic stabilization and for myocardial strengthening by scarring before urgent surgery or permanent device placement.
References [1] Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Circulation 2000;101:27 – 32. [2] Waight DJ, Hijazi ZM. Post-myocardial infarction ventricular septal defect: a medical and surgical challenge. Catheter Cardiovasc Interv 2001;54:488 – 9. [3] Lock JE, Block PC, McKay RG, Baim DS, Keane JF. Transcatheter closure of ventricular septal defects. Circulation 1988;78:361 – 8.