Case

Reports
Percutaneous Repair of
Post-Myocardial Infarction
Ventricular Septal Defect:
Current Approaches and Future Perspectives
Maria D. Baldasare, MD Post-myocardial infarction ventricular septal defect is a devastating complication of ST-
Mark Polyakov, MD elevation myocardial infarction. Although surgical intervention is considered the gold stan-
Glenn W. Laub, MD dard for treatment, it carries high morbidity and mortality rates. We present 2 cases that
Joseph T. Costic, DO
Daniel J. McCormick, DO illustrate the application of percutaneous closure of a post-myocardial infarction ventricular
Sheldon Goldberg, MD, septal defect: the first in a patient who had undergone prior surgical closure and then devel-
FACC oped a new shunt, and the second as a bridge to definitive surgery in a critically ill patient.
(Tex Heart Inst J 2014;41(6):613-9)

T
he occurrence of a ventricular septal defect (VSD) after a myocardial infarc-
tion (MI) is an infrequent but serious sequela, which usually occurs within
the first week.1 In the years before reperfusion became available, the incidence
of VSD after an MI was between 1% and 2%, with an in-hospital mortality rate of
45% with surgery, and 90% with medical management alone.1-4 After the introduc-
tion of reperfusion therapy, the rate of post-MI VSD decreased to 0.2% to 0.34%.4,5
However, mortality rates remain high after surgical intervention, ranging from 20%
Key words: Heart rupture, to 87%, depending on severity in the individual patient and on length of follow-up.5-11
post-infarction; heart septal
defects, ventricular; heart
Because surgery offers a better outcome than medical management alone, imme-
septum/surgery; myocardial diate surgical intervention is now a class I recommendation for post-MI VSD.12,13
infarction/complications; However, early surgical repair can be difficult because of the soft and friable tissue
residual leak; septal oc-
cluder device; shock, cardio-
surrounding the area of infarction and the possibility of VSD expansion.14-16 In addi-
genic; treatment outcome; tion, a residual shunt persists in 10% to 37% of patients despite surgical repair; 11%
ventricular septal rupture of those residual defects need further surgical procedures.7 An approach that would
enable immediate hemodynamic stabilization and closure of the defect is desirable.
From: Divisions of Cardiol- Although transcatheter closure of a post-MI VSD is relatively new, investigators have
ogy, Internal Medicine, and shown that this procedure is well suited for treating residual shunts after surgical clo-
Cardiothoracic Surgery (Drs.
Baldasare, Costic, Laub,
sure and for stabilizing critically ill patients as a bridge to future surgery.17-23 We report
and Polyakov), Drexel Uni- our experience with 2 cases of the percutaneous closure of post-MI VSDs, which
versity College of Medicine, illustrate these principles.
Philadelphia, Pennsylvania
19102; and Division of
Cardiology & Interventional Case Reports
Cardiology (Drs. Goldberg
and McCormick), University Patient 1
of Pennsylvania Health Sys-
tem, Philadelphia, Pennsyl- Transcatheter Closure of Recurrent Shunt after Surgical Repair. A 65-year-old man
vania 19104 presented at our institution’s emergency department with chest pain and shortness
of breath. On physical examination, the patient exhibited signs of congestive heart
Address for reprints: failure, together with a grade 3/6 harsh holosystolic murmur. The patient was hypo-
Sheldon Goldberg MD, tensive, his cardiac enzymes were elevated, and electrocardiographic findings showed
FACC, Pennsylvania Hos­
pital, 800 Spruce St.,
ST-elevation in the anterior leads. An echocardiogram revealed a VSD, an akinetic
Philadelphia, PA 19107 anterior wall, and a hyperdynamic posterior wall. Cardiac catheterization showed criti-
cal left main and multivessel coronary artery disease. The patient’s pulmonary artery
E-mail:
(PA) pressure was 42/22 mmHg, there was an oxygen elevation in the right ventricle
sheldongoldberg66@ (RV), and his PA oxygen saturation was 79%. The Qp/Qs was 2.2:1.
gmail.com The patient underwent successful coronary artery bypass grafting (CABG), to-
gether with Dacron-graft repair of the VSD. One week postoperatively, he developed
© 2014 by the Texas Heart ® increasing dyspnea and had a recurrent holosystolic murmur. He was found on echo-
Institute, Houston cardiography to have a residual VSD (Fig. 1). Repeat angiography showed 2 defects,

Texas Heart Institute Journal http://dx.doi.org/10.14503/THIJ-13-3695 613

localized to the mid and apical septum; the Qp/Qs phy confirmed successful closure of the mid VSD, and
shunt ratio was again 2.1:1. Because the patient was at both fluoroscopy (Fig. 2C) and TEE showed that the
high risk for a 2nd cardiac surgery, percutaneous closure device was appropriately seated.
was recommended. The patient was stabilized and weaned from the IABP
With the patient under general anesthesia, we ob- and mechanical ventilation. Over the course of the
tained bilateral femoral arterial and venous access and following year, the patient experienced recurrent con-
placed an intra-aortic balloon pump (IABP) prophy- gestive heart failure because of severe LV dysfunction,
lactically. Ventriculography performed in the left ante- despite an intact septum. One year after septal defect
rior oblique projection showed 2 separate defects (Fig. closure, the patient underwent cardiac transplantation.
2A). We placed a diagnostic catheter in the left ventricle Examination of the explanted heart showed complete
(LV), and passed a wire into the PA, where it was snared sealing of the septal defect by the occluder device (Fig.
and externalized to the right femoral vein, to form a 3).
continuous arteriovenous loop. The size of the defect
was measured by transesophageal echocardiography Patient 2
(TEE) and fluoroscopy, via a sizing balloon. The VSD Recurrent Shunt after Transcatheter Closure and Subse-
waist size was found to be 9 to 10 mm (Fig. 2B). We quent Surgical Repair. A 73-year-old woman was trans-
loaded an occluder device onto the delivery catheter and ferred from another hospital for the treatment of a VSD
advanced it through the defect. A 28-mm CardioSEAL 4 weeks after an anterior MI. Upon cardiac catheter-
StarFlex® Septal Occluder was used, the distal portion ization, we found total occlusion of the proximal left
of which was deployed on the LV side and anchored suc- anterior descending coronary artery (LAD) and 40%
cessfully by pulling back toward the RV. We deployed stenosis of the right coronary artery. The patient was
the proximal portion of the implant at the RV side of revascularized with 2 drug-eluting stents in the proxi-
the interventricular septum. Repeat left ventriculogra- mal LAD. Left ventriculography showed an LV ejection
fraction (LVEF) of 0.25, with anterolateral akinesia and
apical dyskinesia. The patient had a prolonged hospital
A course complicated by cardiogenic shock, which re-
quired pressor support. She eventually was discharged
from the hospital.
During a follow-up visit with her cardiologist approx-
imately 3 weeks later, she was noted to have profound
heart failure and a 3/6 harsh holosystolic murmur. After
her admission to another hospital, her condition rapidly
deteriorated, to the point that she was given inotropic
support. An echocardiogram showed persistently de-
creased LVEF and a new VSD.
The patient was then transferred to our institution for
further management of her VSD. A repeat echocardio-
gram showed a 14- to 16-mm apical VSD with an LVEF
of 0.30 and a dysfunctional RV with moderate tricuspid
B regurgitation. Right-sided heart catheterization showed
a PA pressure of 67/45, a PA oxygen saturation level of
77%, and a Qp/Qs ratio of 3.6. The patient needed
an IABP with inotropic support to maintain hemody-
namic stability. Because she was considered a high-risk
surgical candidate, she underwent percutaneous closure
of her VSD.
A TEE identified the defect, the diameter of which
was 1.4 cm. This was followed by ventriculography.
Crossing the VSD proved difficult, and multiple cath-
eters were used. We crossed the defect from the LV and
externalized a guidewire via the femoral venous sheath.
A sheath was then brought into the RV from the right
Fig. 1 Patient 1. Transthoracic echocardiograms (subcostal view)
femoral vein and was introduced into the LV, where
show A) a ventricular septal defect (arrow) and B) further delinea- it was used to deliver an 18-mm A mplatzer ® Septal
tion with use of color-flow Doppler. Occluder (St. Jude Medical, Inc.; St. Paul, Minn). Po-
sitioning of the occluder was optimized via TEE and

614 Percutaneous Repair of Post-MI VSD Volume 41, Number 6, 2014

 A B C

Fig. 2 Patient 1. Coronary angiograms (left anterior oblique view) show A) 2 separate ventricular defects (arrows); B) the defect’s waist
size, measured via a balloon catheter; and C) the deployed septal occluder.

A (and 6 weeks post-MI), the patient underwent surgical

repair. Intraoperatively, we found a residual VSD at the
inferior border of the occluder device. We removed the
Amplatzer occluder and repaired the defect with a Cor-
Matrix ® patch (CorMatrix; Roswell, Ga). The patient
tolerated the procedure and eventually was weaned from
the IABP and inotropic support. She was discharged
from the hospital free of angina, but her LVEF was per-
sistently reduced, at 0.15.

Discussion
Surgical repair of a post-MI VSD is associated with a
very high mortality rate.19 The 2004 and 2007 Ameri-
can College of Cardiology/American Heart Association
guidelines recommend emergent repair of the VSD
B with concurrent CABG, regardless of hemodynamic
status.12,13 Acute post-MI VSD repair is difficult because
of the soft and friable myocardial tissue. It has been sug-
gested that better results occur when the tissue edges
surrounding the VSD have scarred and myocardial
fibrosis has produced more favorable surgical condi-
tions.14-16 The improved surgical survival rate associated
with delayed repair carries a significant selection bias,
for it encompasses patients who have a relatively lower
risk for surgery.
Within recent years, the percutaneous closure of post-
MI VSDs has become a promising option in a variety
of situations: to close a residual leak after VSD surgical
repair, to stabilize high-risk patients for future surgery,
Fig. 3 Patient 1. Intraoperative photographs show A) the explant- and to serve as a primary intervention.
ed heart, with an intact septal occluder device; and B) a closer
view of that device (arrows).
The application of occluder devices to recurrent post-
MI VSDs has been reported in several series.17,18,24 Recur-
rence of a VSD occurs in 5% to 20% of surgical repair
ventriculography. We used a push-pull maneuver to cases.25-27 The considerable advantage of a percutaneous
confirm good seating of the device, then deployed it. approach to repeat VSD repair is that the patient does
At first, the patient’s clinical condition improved, not undergo a 2nd surgery.
but it steadily worsened and repeat imaging showed a After an initial large study by Landzberg and Lock,27
persistent VSD. Two weeks after percutaneous closure Holzer and colleagues 17 reported the immediate and

Texas Heart Institute Journal Percutaneous Repair of Post-MI VSD 615

midterm results of a multicenter international registry initially stabilize a high-risk patient, provide additional
of transcutaneous closure of post-infarction VSDs. The tissue-recovery time, and afford easy removal at opera-
Amplatzer muscular VSD device (St. Jude Medical) tion without impeding surgical closure.22,31
was successfully deployed in 16 of 18 patients (89%); In the largest study to date, Thiele and colleagues 5
10 of those 18 patients (56%) had undergone a previous evaluated (in an acute setting, with 29 patients) the ap-
attempt at primary surgical closure and had experienced plication of primary transcatheter closure of post-MI
residual shunting. The median time between MI and VSDs. Sixteen of the 29 patients (55%) presented in
transcatheter closure of the VSD was 25 days. At 24 cardiogenic shock, and successful device deployment
hours after closure, the residual shunt was measured: 2 was achieved in 25 of the 29 (86%). The median time
of the 16 VSDs with successful device deployment were from MI to VSD was 2 days, and the median time from
closed (12.5%), 10 displayed trivial or small residual the VSD occurrence to percutaneous device closure was
shunting (62.5%), and 4 displayed moderate or large 1 day. The 30-day survival rate was only 35%. The long-
shunts (25%). The 30-day mortality rate was 28%. Of term mortality rate (median follow-up, 730 d) of pa-
the 16 patients, only 2 (12.5%) required a 2nd proce- tients who developed a VSD, presented in cardiogenic
dure to close a residual VSD. shock, and underwent successful device implantation
Goldstein and associates 18 discussed the morbidity was 93%. However, patients who developed VSD, did
and death associated with surgical repair of post-MI not experience cardiogenic shock, and underwent suc-
VSDs. In their judgment, the impetus behind the de- cessful device implantation had both 30-day and long-
velopment of percutaneous methods was the general term mortality rates of 36%.
reluctance of surgeons to attempt repeat surgical repair Our review of interventional postinfarction VSD pro-
of post-MI VSDs. Several other investigators24,28-30 have cedures (Table I) is limited to case reports and small
suggested the improvement in heart failure symptoms series.5,17-22,24,28-46 Most such patients underwent VSD clo-
as an impetus, together with the option of a treatment sure in the chronic or subacute phase, or experienced
alternative for critically ill patients. residual shunting after surgical patch closure.5 This
We report our experience in treating Patient 1, who summary presents the results of a prospective series in
presented with a residual post-MI VSD one week after which all patients with post-MI VSDs were treated in
undergoing surgical repair of the VSD. His case illus- the acute setting, whether or not they were in severe
trates the successful use of percutaneous techniques in cardiogenic shock. We attribute the high mortality rate
order to close a post-MI VSD in a patient who is at high to the selection of “all comers”; these outcomes cannot
risk for repeat surgery. An unusual feature of the case is be compared with those of a surgical series, given the
the availability of the patient’s explanted heart, which small number of patients and the inherent selection bias.
enabled direct viewing of the successfully deployed clo- Concomitant cardiogenic shock, which might be
sure device. Consistent with previous reports, this report present in these patients, is an important predictor of
shows that the staged approach was effective in avoiding increased mortality rates. It seems reasonable to infer
a 2nd operation in a critically ill patient. We believe that that outcomes in these patients (Table I) would have
this technique can be used for acute or permanent con- improved, had mechanical circulatory support been
trol of VSD expansion after initial surgical repair. used to stabilize circulation of the blood before per-
Two separate case reports recently discussed the im- cutaneous or surgical repair. In one case series 47 not
portance of managing patients who are too ill to under- included in Table I, an IABP was used in 23 patients
go early surgical closure of post-MI VSD.22,31 Although who had post-MI VSDs. Patients who underwent early
delaying the closure of the VSD in such patients can surgical repair had an 83% mortality rate, whereas pa-
result in a state of progressive multisystem failure, ini- tients who were stabilized before surgical closure had
tial therapy through percutaneous closure can serve as an early mortality rate of 29% and an overall mortality
a bridge to future surgical intervention.31 rate of 56.5%. These patients were under IABP support
We also report the case of Patient 2, who presented for a range of 1 to 26 days. Conversely, in a study by La
with a VSD 4 weeks after the MI. The patient needed Torre and colleagues,48 5 patients in cardiogenic shock
inotropic support to maintain hemodynamic stability as a result of post-MI VSD underwent placement of the
and was at very high surgical risk. The decisions to avoid Impella ® Recover ® LP 5.0 Support System (Abiomed
surgery because of the mortality rate associated with Inc.; Danvers, Mass), in an effort to stablilize them
acute repair, and to stabilize the patient through percu- before VSD repair. Two of the 5 died after surgical
taneous intervention, led to our successfully bridging repair. In another case report,49 the TandemHeart® per-
her to surgery. We believe that the closure of post-MI cutaneous ventricular assist device (CardiacAssist Inc.;
VSDs in patients who are at extraordinary risk for op- Pittsburgh, Pa) was used in a case of posterior post-MI
eration affords extra time for improved tissue integrity, VSD for a total of 18 days, which enabled hemody-
which can greatly strengthen future operative repair. As namic stability and subsequent successful repair of the
a bridge to surgery, a percutaneous closure device can defect.

616 Percutaneous Repair of Post-MI VSD Volume 41, Number 6, 2014

TABLE I. Reports of Percutaneous Transcatheter Closure of Post-Myocardial Infarction Ventricular Septal Defects

Survival Residual
Prior at 30 Days Shunt
No. Surgical Occluder Success
Reference Patients Acute S/C Repair Devices Rate Acute S/C Tr–Sm Mod–Sv

Landzberg MJ and 18 NA NA 11 CardioSeal 17/18 NA NA NA NA

Locke JE28 (1998)
Lee EM, et al.29 (1998) 1 0 1 1 ASO 1/1 — 1/1 1 —
Pesonen E, et al.32 (2000) 2 0 2 2 ASO 2/2 — 2/2 2 —
Mullasari AS, et al. (2001) 30
1 1 0 0 ASO 1/1 1/1 — 1 —
Pienvichit P and 1 1 0 0 CardioSeal 1/1 0/1 — — 1
Piemonte TC33 (2001)
Parsi A, et al.34 (2001) 2 1 1 0 MVSDO 2/2 0/1 1/1 — —
Chessa M, et al.35 (2002) 12 3 9 NA MVSDO 11/12 0/3 8/9 NA NA
Goldstein JA, et al. (2003) 18
4 0 4 4 PIMVSDO 3/4 — 3/3 2 2
Szkutnik M, et al. (2003)
36
7 0 7 1 4 ASO and 5/7 — 4/5 3 1
5 MVSDO
Zanchetta M, et al.37 (2003) 1 1 0 0 ASO 1/1 NA NA NA NA
Demkow M, et al.38 (2005) 11 3 8 0 NA 10/11 0/2 9/9 8 2
Elsässer A, et al. (2005) 1 0
39
1 0 PIMVSDO 1/1 — 1/1 1 —
Holzer R, et al. (2006)
17
18 5 13 10 PIMVSDO 16/18 2/5 9/13 8 2
Martinez MW, et al.40 (2006) 1 1 0 0 PIMVSDO 1/1 NA NA 1 —
Martinez MW, et al.19 (2007) 5 3 2 1 2 ASO, 2 MVSDO, 5/5 2/3 2/2 3 1
and 2 PIMVSDO
Kaulfersch C, et al.21 (2007) 22 22 0 0 NA 17/22 NA NA NA NA
Costache VS, et al. (2007) 31
1 1 0 0 NA 1/1 1 — NA NA
Bialkowski J, et al.41 (2007) 19 1 18 2 17 ASO, 2 MVSDO, 14/19 0/1 9/13 9 3
and 2 PIMVSDO
Marinakis A, et al.42 (2007) 8 6 2 0 MVSDO 7/8 0/6 1/2 NA NA
Ahmed J, et al. (2008)
43
5 2 3 2 MVSDO and 4/5 0/1 3/3 3 1
PIMVSDO
Giombolini C, et al.44 (2008) 1 0 1 0 AMASDO 1/1 — 0/1 1 —
Thiele H, et al. (2009)
5
29 29 0 0 ASO, MVSDO, and 25/29 10/29 — 6 4
PIMVSDO
Maltais S, et al.20 (2009) 12 12 0 0 PIMVSDO 11/12 7/11 — 10 1
Sun Y, et al.45 (2009) 12 0 12 NA NA 9/12 NA NA NA NA
Gulkarov IM, et al. (2010) 1 0
24
1 1 MVSDO 1/1 — 1/1 0 0
Avgerinos DV, et al. (2011) 22
1 1 0 0 NA 1/1 1/1 — 0 1
Yalcin Y, et al.46 (2011) 1 0 1 1 Cardio-O-Fix 1/1 — 1/1 0 0

AMASDO = Amplatzer Atrial Septal Defect Occluder; ASO = Amplatzer Septal Occluder; CardioSeal = CardioSeal Septal Occluder;
MVSDO = Amplatzer Muscular Ventricular Septal Defect Occluder; Mod = moderate; NA = not available; PIMVSDO = Amplatzer
Post-infarction Ventricular Septal Defect Occluder; S/C = subacute/chronic; Sm = small; Sv = severe; Tr = trivial

It seems plausible that percutaneous mechanical sup- devices can be used for high-risk percutaneous coro-
port might stabilize patients who are in cardiogenic nary artery intervention, and as an adjunct to surgical
shock as a sequela to their post-MI VSDs. Several case repair.50 Myocardial revascularization in conjunction
reports have described the management of hemody- with VSD repair is imperative.
namic dysfunction through the use of an IABP, an axi-
al-flow pump, or a TandemHeart, with various results. Conclusion
The use of such devices in this circumstance will require There is evidence supporting transcatheter device clo-
more extensive study and experience. In addition, these sure of post-MI VSDs. Although the gold standard is

Texas Heart Institute Journal Percutaneous Repair of Post-MI VSD 617

still surgical repair with concurrent CABG, the applica- 11. Mantovani V, Mariscalco G, Leva C, Blanzola C, Sala A.
tion of this therapy to all patients might not be reason- Surgical repair of post-infarction ventricular septal defect: 19
years of experience. Int J Cardiol 2006;108(2):202-6.
able, especially when patients are critically ill or have 12. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green
multiple comorbidities. An interventional approach LA, Hand M, et al. ACC/AHA guidelines for the manage-
offers such patients the possibility of avoiding a major ment of patients with ST-elevation myocardial infarction--­
operation. The ability to manage a post-MI VSD in executive summary: a report of the American College of
the acute setting can afford benefit—whether it be the Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Revise the 1999
closure of a residual defect after surgical repair or the Guidelines for the Management of Patients with Acute Myo-
provision of an opportunity to heal septal tissue in prep- cardial Infarction) [published erratum appears in Circulation
aration for final closure. It should be emphasized that 2005;111(15):2013]. Circulation 2004;110(5):588-636.
the mortality rate after transcatheter closure remains 13. Antman EM, Hand M, Armstrong PW, Bates ER, Green
high, especially in the setting of cardiogenic shock. The LA, Halasyamani LK, et al. 2007 Focused Update of the
ACC/AHA 2004 Guidelines for the Management of Pa-
high mortality rate in patients with post-MI VSD has tients with ST-Elevation Myocardial Infarction: a report of
not changed substantially during the last 2 decades.51 It the American College of Cardiology/American Heart As-
is feasible that the combined use of ventricular support, sociation Task Force on Practice Guidelines: developed in
more complete revascularization, and earlier interven- collaboration with the Canadian Cardiovascular Society
tion will improve future outcomes. endorsed by the American Academy of Family Physicians:
2007 Writing Group to Review New Evidence and Update
the ACC/AHA 2004 Guidelines for the Management of
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