Structural Heart Disease > Cases

Transcatheter Closure of a Postmyocardial Infarction Ventricular Septal Rupture with an Amplatzer Septal Occluder
- Operator: Mahsa Fadavi, MD
Clinical Information
- Relevant clinical history and physical exam:
A 70 years old physician with a large acute anterior myocardial infarction who underwent thrombolytic therapy with streptokinase, but chest pain and ST segment elevation persisted. then Emergent coronary angiography performed several hours after admission and showed severe three vessel diseases. (Figure 1, Figure 2) Echocardiography showed anteroseptal akinesia and LV dysfunction( LVEF=25% ) , with mild MR and without ventricular septal rupture. . He underwent emergency coronary artery bypass grafting . The patient remained stable until the third post-CABG day when he developed tachycardia, hypotension, dyspnea, pulmonary edema, and a new pansystolic murmur heard over the left sternal border. Intravenous inotropes were started. Repeated bedside echocardiography showed anteroseptal akinesia and a mid-septal VSD with mild MR and without pericardial effusion. (Figure 3) Transoesophageal echocardiography (TEE) and cardiac catheterization showed a 8 mm diameter VSD with significant left to right shunt, pulmonary hypertension (45mm Hg). The inferior and posterior left ventricular walls contracted well but septum and apex were akinetic.then he underwent amplatzer septal occluder.

- Relevant test results prior to catheterization:
echocardiography and transoesophageal echcardiography(TEE)

- Relevant catheterization findings:
ventricular septal defects (VSD)

Interventional Management

- Procedural step:
The VSD was crossed using a retrograde arterial approach with a 7 F El Gamal catheter and Wholey wire. The El Gamal catheter was advanced into the pulmonary artery or right atrium over the Wholey wire, which was then exchanged for a 0.035 inch guidewire. The end of this wire was then snared in the pulmonary artery or RA with a 25 mm Amplatzers goose-neck snare and then extruded via the right internal jugular vein, thereby creating an arteriovenous guidewire loop. In this patient because of difficulty and failure in retrograde femoral artery approach, a multipurpose A1 catheter was advanced from femoral vein into the RV and then LV via VSD. A 0.035 inch, 300 cm length amplatzer guidwire advanced from VSD into the LV and then ascending and descending aorta for better support. A 9 F long sheath was advanced from the femoral vein into the left ventricle. (Figure 4) A 20 mm Amplatzer septal occluder was screwed onto the delivery cable, compressed into the loader, and introduced into the long sheath. The distal disc was extruded and pulled back onto the left ventricular side of the septum under TEE guidance. (Figure 5) Once TEE confirmed septal alignment, the proximal (right ventricular) disc was deployed. The device was then released by counterclockwise rotation of the delivery wire. (Figure 6, Figure 7) Left ventriculography did not perform following procedure but TEE showed only trivial left to right shunting through the device.

if already fenoral artery was used to pass el gamal catheter then why it has been mentioned that femoral retrograde passage was difficult. when wholey was passed from lv to rv then why this sentence was written .
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