Fig. 27.1
Transthoracic echocardiography (TTE) images (a) 2D parasternal short axis, (b) Doppler parasternal short axis, and (c) Doppler four chamber depicting the ventricular septal defect (VSD) (white arrows). Magnetic resonance imaging (d) long axis and (e) short axis magnifying the ventricular communication (white arrows)
Tricuspid valve regurgitation 2/4
The patient had recurrent episodes of heart failure and was subsequently referred to our institution for further investigation and treatment. Cardiac magnetic resonance imaging (MRI) was performed and confirmed the presence of a 9-mm ventricular septal defect at the junction of the mid- and inferior septum and a transmural infarct on late enhancement imaging (Fig. 27.1d, e). There was a significant, left-to-right shunt with a pulmonary-to-systemic blood flow ratio (Qp/Qs) equal to 2.
Given the clinical presentation of the patient, as well as the echo and MRI findings, the decision was made for percutaneous VSD closure.
27.3 Percutaneous VSD Closure
Following patient consent, percutaneous VSD closure was planned using the following strategy: general anesthesia and intraprocedural transesophageal echo to guide device closure using an Amplatzer Post-MI VSD Occluder. The preferred strategy was to cross the ventricular septal defect anterogradely following transseptal puncture and then close the defect with the appropriately sized device.
The steps of the procedure were as follows:
- 1.
Vascular access and vessel pre-closure using Perclose ProGlide (Abbott Vascular).
- 2.
The VSD was measured by TEE color Doppler imaging to determine the largest diameter. Given the friable nature of post-MI VSDs, balloon sizing was not done, and device choice was made on the basis of the echo and MRI measurements, 8–9 mm (Fig. 27.2). TEE guided transseptal puncture using 8-French (Fr) Mullins sheath and Brockenbrough needle with placement of the Mullins catheter in the left atrium (Fig. 27.3a–c). Intravenous heparin was given following transseptal puncture to maintain an activated clotting time (ACT) >250 s.
Fig. 27.2
Transesophageal echocardiography (TEE) images showing intraprocedural measurements (a–c) and Doppler evaluation (d) of septal defect for the sizing of the VSD occluder
Fig. 27.3
TEE images showing (a–c) the transseptal puncture technique and (d) the advancing of the Mulling sheath through the VSD from the left-to-the right ventricle (white arrow)
- 3.
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A 7-Fr balloon-tipped catheter (arrow) was advanced on a 0.35-mm wire into the left atrium (Fig. 27.4a). The balloon was inflated, and the catheter was then guided across the mitral valve into the left ventricle (Fig. 27.4b) and then across the ventricular septal defect into the right ventricle (Fig. 27.4c). Once on the right side, the balloon-tipped catheter was then advanced into the pulmonary artery (Figs. 27.3d and 27.4d ).
Fig. 27.4
Schematic representation of the advancement of the balloon-tipped catheter: into left atrium through the transseptal puncture (a), left ventricle through the mitral valve (b), right ventricle through the VSD (c), and finally into the pulmonary artery (d), RA right atrium, LA left atrium, LV left ventricle, RV right ventricle, Ao aorta, PA pulmonary artery
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