Ann Thorac Surg 2010;89:e48-e50. doi:10.1016/j.athoracsur.2010.03.081
© 2010 The Society of Thoracic Surgeons
Case Reports
Intraoperative Device Closure of Postinfarction Ventricular Septal Defects
Michael S. Lee, MD*,a,
Rebecca Kozitza, BA*,a,
Daniel Mudrick, MD, MPHa,
Matthew Williams, MDb,
Andrew J. Lodge, MDb,
J. Kevin Harrison, MDa,
Donald D. Glower, MD*,b,*
a Department of Medicine, Duke University Medical Center, Durham, North Carolina
b Department of Surgery, Duke University Medical Center, Durham, North Carolina
Accepted for publication March 22, 2010.
* Address correspondence to Dr Glower, Duke University Medical Center, Box 3851, Durham, NC 27710 (Email: glowe001{at}mc.duke.edu).
 |
Abstract
|
|---|
Postinfarction ventricular septal defects (VSDs) are associated with high mortality and typically these are treated urgently with surgery for exclusion patch repair. Percutaneous closure of postinfarction VSDs using occlusion devices is feasible in some patients, but in some cases device deployment may not be possible due to VSD anatomy or valvular apparatus interference. We report the novel technique of deploying Amplatzer VSD devices in the operating room under direct vision through a right atriotomy with and without aortotomy in 2 patients with large inferobasal VSDs after myocardial infarction.
|
Introduction
|
|---|
Postinfarction ventricular septal defects (VSDs), especially when complicated by cardiogenic shock, remain difficult to treat and carry a high risk of mortality [1, 2]. In patients with posterobasal VSDs, ventriculotomy with exclusion patch repair can be especially challenging and risky, requiring retraction of the heart anteriorly to expose the infarcted inferior wall. We present the first reported deployments of ventricular septal occluding devices in operative hybrid procedures for postinfarction VSDs.
|
Case Reports
|
|---|
Patient 1
A 68-year-old man presented with cardiogenic shock after 5 days of chest pain and progressive dyspnea. An electrocardiogram showed acute inferior myocardial infarction (MI). An angiogram revealed 100% proximal right coronary occlusion, 90% proximal left anterior descending coronary artery stenosis, and an inferobasal VSD demonstrated by ventriculography (Fig 1). An intra-aortic balloon pump was placed, and the patient subsequently required intubation.
View larger version (184K):
[in this window]
[in a new window]
|
Fig 1. Left ventriculogram of patient 1. Left anterior oblique view, cranial projection. Note the tangential geometry of the ventricular septal defect (VSD) relative to the plane of the septum, and the right ventricle (RV) exit site beneath the septal leaflet of the tricuspid valve (arrow). (* = ventricular septal defect; arrow = tricuspid valve septal leaflet; LV = left ventricle.)
|
|
Given the patient's clinical status and the location of the VSD, percutaneous closure with an Amplatzer muscular VSD occluder (AGA Medical Corp, Plymouth, MN) was attempted in the catheterization laboratory using femoral arterial and right internal jugular venous access. Delivery of the delivery sheath and device from the right ventricular side was prevented by interference from the septal leaflet of the tricuspid valve. Through the femoral artery, the delivery sheath was of inadequate length to position the device from the left ventricular side.
The patient was taken to surgery and placed on cardiopulmonary bypass through a sternotomy. The right atrium and ascending aorta were opened, and a 16-mm VSD was directly visualized and palpated (Fig 2A). An 18-mm Amplatzer muscular VSD occluder (AGA Medical, Plymouth, MN), compressed in the insertion catheter and attached to the delivery cable, was inserted through the right atrium, advanced through the tricuspid valve into the VSD, and deployed. Placement was guided by tactile manipulation and direct visualization (through both the aortic valve on the left and the tricuspid valve on the right), while being careful to avoid interference with the adjacent tricuspid valve chordae (Figs 2B–2D). Coronary artery bypass grafting (CABG) and tricuspid annuloplasty were then performed.
View larger version (130K):
[in this window]
[in a new window]
|
Fig 2. Intraoperative photographs at the time of ventricular septal defect (VSD) closure of patient 1. (A) Visualization of the VSD (arrow) from the right ventricle (RV) side after surgical opening of the right atrial free wall and retraction of the tricuspid valve septal leaflet. (B) Placement of the Amplatzer muscular VSD occluder with attached delivery cable visualized from the RV side. (C) The Amplatzer device released from the delivery cable, visualized from the RV side. Note freedom of the tricuspid valve chordae tendinae from the VSD device. (D) The Amplatzer device seated in its final position, visualized from the left ventricle side through an aortotomy.
|
|
Initially, ventilator and dialysis support were required, but the patient was transitioned off of these on postoperative days 7 and 13, respectively, and the patient was transferred out of intensive care on day 18. Follow-up echocardiography on day 21 revealed a trivial left-to-right shunt across the VSD, normal left and right ventricular systolic function, and trivial tricuspid regurgitation. The patient ultimately died of abdominal sepsis unrelated to the VSD or VSD device on hospital day 50.
Patient 2
A 64-year-old man without known history of myocardial infarction presented with New York Heart Association functional class III heart failure symptoms. Cardiac catheterization revealed severe pulmonary hypertension, three-vessel coronary artery disease, and a large VSD with pulmonary-to-systemic flow ratio greater than 3:1.
A cardiac magnetic resonance image showed a 1-cm inferobasal septal aneurysm communicating with the right ventricle just beneath the posterior tricuspid leaflet. Hyper-enhancement in the region of the VSD suggested prior myocardial infarction with subsequent rupture as the cause. Left ventricular ejection fraction was 65%, with no other regional wall motion abnormalities (Fig 3).
View larger version (99K):
[in this window]
[in a new window]
|
Fig 3. Cardiac magnetic resonance image of patient 2. Short-axis and posterior four-chamber view of the septal defect in the basal inferior portion of the ventricular septum. (LV = left ventricle; RV = right ventricle; VSD = ventricular septal defect.)
|
|
In the operating room, after a median sternotomy, cardiopulmonary bypass was initiated, CABG was completed, and a right atriotomy was performed. Within a fibrotic area in the posterobasal septum, under the posterior leaflet of the tricuspid valve, the VSD was identified with multiple points of entry into the right ventricular chamber. A 16-mm Amplatzer muscular VSD occluder was inserted across the VSD by using the delivery cable and the loading catheter. After the left ventricular side was deployed, traction was applied to ensure proper placement, and the right ventricular disc was then deployed under direct vision. The device was secured with a single 4-0 Prolene suture (Ethicon, Somerville, NJ) sewn to the right ventricular side of the septum.
The interventricular septum was further inspected, and several apical VSD exits were also identified and closed with 4-0 Prolene pledgeted sutures (Ethicon), and a Dacron patch (Boston Scientific, Wayne, NJ) was secured to the margins of the VSD. The tricuspid valve was tested and appeared competent. Transesophageal echocardiography showed trivial residual VSD shunting and normal biventricular function, without obstruction of the left ventricular outflow tract by the VSD occluder device.
The patient had an uneventful postoperative course. Serial postoperative echocardiograms showed a stable position of the VSD occluder device with trivial residual flow. The patient was discharged home on postoperative day 7 and continues to do well on follow-up more than 5 months postoperatively.
|
Comment
|
|---|
The role of VSD occluding devices in the management of postinfarction VSDs is evolving. These devices were initially developed for percutaneous closure of congenital muscular VSDs [3]. Percutaneous placement has been increasingly used in patients with postinfarction VSDs, initially in patients with recurrent VSDs after primary surgical repair, but more recently as primary therapy in patients with acute ventricular septal rupture and high surgical risk, or as a temporizing bridge to surgery [4, 5]. Percutaneous deployment of an occluding device may be precluded by the geometry and location of the VSD, or interference from valvular apparatus, especially in basilar ruptures as in the 2 patients presented.
Operative hybrid approaches for device closure of congenital muscular VSDs in children have been successfully performed, with atrial and perventricular approaches (through a right ventricular puncture) being described [6, 7]. However, there were no prior cases reported of operative hybrid deployment of VSD closure devices in postinfarction VSDs. The use of a hybrid approach allows VSD closure without the need to perform ventriculotomy in an already compromised, infarcted ventricle. This approach also allows direct manipulation of the device to prevent interference of the valve apparatus, device stabilization with sutures, augmentation with patch repair, and reduction in cardiopulmonary bypass times, relative to typical surgical repair. The optimal approach to postinfarction VSD continues to evolve, but this hybrid approach offers an alternative to classical surgical repair and percutaneous device closure.
|
Footnotes
|
|---|
* Equally contributing primary authors. 
|
References
|
|---|
- Labrousse L, Choukroun E, Chevalier JM, et al. Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death and long term results Eur J Cardiothorac Surg 2002;21:725-731.[Abstract/Free Full Text]
- Maltais S, Ibrahim R, Basmadjian AJ, et al. Postinfarction ventricular septal defects: towards a new treatment algorithm? Ann Thorac Surg 2009;87:687-692.[Abstract/Free Full Text]
- Holzer R, Balzer D, Cao QL, Lock K, Hijazi ZM. Amplatzer muscular ventricular septal defect investigators. Device closure of muscular ventricular septal defects using the Amplatzer muscular ventricular septal defect occluder: immediate and mid-term results of a U.S. registry. J Am Coll Cardiol 2004;43:1257-1263.[Abstract/Free Full Text]
- Goldstein JA, Casserly IP, Balzer DT, Lee R, Lasala JM. Transcatheter closure of recurrent postmyocardial infarction ventricular septal defects utilizing the Amplatzer postinfarction VSD device: a case series Catheter Cardiovasc Interv 2003;59:238-243.[Medline]
- Thiele H, Kaulfersch C, Daehnert I, et al. Immediate primary transcatheter closure of postinfarction ventricular septal defects Eur Heart J 2009;30:81-88.[Abstract/Free Full Text]
- Bacha EA, Cao QL, Galantowicz ME, et al. Multicenter experience with perventricular device closure of muscular ventricular septal defects Pediatr Cardiol 2005;26:169-175.[Medline]
- Baird CW, Stern H, Watts L. Left atrial hybrid closure of muscular ventricular septal defects with the Amplatzer device J Thorac Cardiovasc Surg 2009;137:779-780.[Free Full Text]
Top
Abstract
Introduction
