Based on the existing literature, a variety of devices for percutaneous closure of postinfarction VSR have been used. These devices are the atrial septal defect occluder, muscular ventricular septal defect occluder, and recently a dedicated postinfarction muscular ventricular septal defect occluder device developed by Amplatz (Fig. 25.3). The diameters of the applied devices are, on purpose, significantly larger than the diameter of the VSR measured using different imaging techniques. The strategy to “oversizing” is particularly important when closures are attempted in the acute phase. In this situation the optimal diameter should be twice the size of the measured VSR diameter or at least 10-mm larger [28, 29]. This prevents incomplete closure or dislodging and subsequent embolization of the device due to continued septal necrosis. Instead, occlusion in the chronic phase requires occluding devices sized only 4–7-mm larger than the VSR [30]. The choice of the most suitable device is not certain and varies from case to case: generally the specific postinfarction muscular ventricular septal defect occluder device developed by Amplatz is considered by many authors the most suitable. This device has a wider waist, larger disks, and a denser construction, which should lead to a faster occlusion over a wider septal region. Therefore, larger disks are likely to cover any accessory VSR that often accompanies the main VSR [30–32]. The use of atrial septal defect occluder should be utilized only in particular cases: the combination of a high-pressure gradient between the two ventricles and the high permeability makes this device unable to provide a complete occlusion of the VSR.

The technique of percutaneous closure of a postinfarction VSR is based upon the well-proven and widely used percutaneous technique for closing a congenital ventricular septal defect. Color Doppler echocardiography is used to determine the size and the anatomy of the VSR. Other imaging methods, such as computed tomography, could be utilized to obtain more detailed informations.

The procedure is performed under fluoroscopic and echocardiographic guidance. All patients receive antibiotic prophylaxis as well as aspirin (500 mg) and heparin (60 UI/Kg) intravenously maintaining the activating clotting time over 300 s.

Cannulation of the femoral artery and femoral vein or jugular vein is performed using Seldinger technique. A guidewire is introduced into the artery, through the aortic valve. The injection of contrast medium in left ventricle (oblique lateral view) is utilized to visualize the position of VSR (Fig. 25.4). The use of catheters with radiopaque markers is useful for making measurements of VSR during the procedure.

The VSR is generally crossed from the left ventricle using a diagnostic right Judkins or a multipurpose catheter, and a soft or hydrophilic long wire is advanced into the pulmonary artery or in superior vena cava (Fig. 25.5a). The wire is then snared using a Gooseneck snare device and exteriorized out of the vein, thereby establishing an arterial-venous circuit (Fig. 25.5b). The delivery sheath is advanced from the venous side loop over the guidewire through the VSR into the left ventricle (Fig. 25.6). Using fluoroscopy and echocardiography, correct positioning of the delivery sheath is confirmed. The guidewire is then retracted leaving the delivery sheath in position (Fig. 25.7). Once echocardiography confirmation of the necessary device size has been achieved, the device is placed inside its catheter and advanced through the VSR using the delivery sheath. The distal disk is opened (Fig. 25.8) and then the device is retracted, so that it will be secured against the septal tissue at the side of the left ventricle. Then the proximal disk is opened by further retracting the delivery sheath. Correct positioning of the device and closure are confirmed by echocardiography and by fluoroscopy. An injection of dye is useful to confirm the right position; then if placement is satisfactory, the device is released (Figs. 25.9 and 25.10). Computed tomography (CT) scan and ventricular angiography can be performed in follow-up to confirm the correct position of the device and the complete repair of septal rupture without any passage of contrast medium in the right ventricle (Figs. 25.11 and 25.12).