Closure of post-myocardial infarction ventricular septal defect with use of intracardiac echocardiographic imaging and percutaneous left ventricular assistance.

A 67-year-old man presented at another hospital with an anterior-wall myocardial infarction. He was transferred to our institution after he went into progressive cardiogenic shock and developed a post-myocardial infarction apical ventricular septal defect (VSD). During high-dose inotropic support, his blood pressure was 78/34 mmHg. Cardiac catheterization revealed a pulmonary artery pressure of 71/30 (48) mmHg and a Qp/Qs ratio of 3.75:1. The cardiogenic shock was refractory, so a TandemHeart percutaneous ventricular assist device (Cardiac Assist, Inc.; Pittsburgh, Pa) was implanted. The patient’s left atrial pressure is shown in Figure 1. Intracardiac echocardiography from the right ventricle was used to inspect the left ventricle and the VSD (Figs. 2 and 3). A sagittal view of the septum enabled accurate measurement of the defect (Figs. 4 and 5). On the basis of compassionate use, percutaneous closure of the VSD was performed with a 24-mm Amplatzer postinfarction VSD occluder (St. Jude Medical, Inc.; St. Paul, Minn) (Fig. 6). A small residual leak was noted. Three weeks after the procedure, the patient died of pancreatitis. The VSD was clearly visible at autopsy (Fig. 7).