Transcatheter Closure of Post–Myocardial Infarction Ventricular Septal Rupture Using an Atrial Septal Defect Occluder

Figure 1. Findings on Admission (A) The electrocardiogram showed sinus rhythm with abnormal Q waves in leads V1-V4 and ST-segment elevations in leads V2-V6. (B) The chest x-ray showed cardiomegaly (cardiothoracic ratio, 64%). (C to E) TTE demonstrated a ventricular septal rupture with left-to-right shunting on the parasternal short-axis view (C and D) and apical 3-chamber view (E). (F and G) Coronary angiography demonstrated the left anterior descending artery was completely occluded, whereas the left circumflex artery and the right coronary artery were patent. TTE = transthoracic echocardiography.

Figure 2. Contrast-Enhanced CT for Procedural Planning (A and B) Contrast-enhanced CT images showing the planes used for reconstruction (red dashed lines). (C) Reconstructed cross-sectional image demonstrating an oval-shaped VSR with maximum and minimum diameters of 16.9 mm and 12.3 mm, respectively. The apical rim measured 7.2 mm at its narrowest point, with adequate circumferential rim length. CT = computed tomography; LV = left ventricle; RV = right ventricle; VSR = ventricular septal rupture.

Figure 3. Transcatheter Closure of VSR (A) Left ventriculography demonstrated a left-to-right shunt through the VSR defect. (B) EN Snare introduced via the left subclavian vein was used to capture the wire advanced from the left brachial artery through the defect, creating an arteriovenous loop. (C) Balloon sizing was performed demonstrating the defect diameter of 16.0 mm. (D) A 17-mm Amplatzer septal occluder was deployed with the left atrial disc positioned in the left ventricle and the right atrial disc in the right ventricle. (E) Final left ventriculography after device release demonstrated appropriate device position with reduced residual shunt. (F) TEE demonstrated the left ventricular disc on the transgastric short-axis view. (G) TEE demonstrated both discs positioned on either side of the interventricular septum, effectively sandwiching it. (H) TEE confirmed reduction of the residual shunt after device release. CRA = cranial; LAO = left anterior oblique; TEE = transesophageal echocardiography; VSR = ventricular septal rupture.

Figure 4. Tricuspid Regurgitation Before and After the Procedure (A) Preprocedural TEE demonstrated the severe TR. (B) Preprocedure TEE demonstrated a VSR jet directed toward the tricuspid valve, likely contributing to TR. (C) Preprocedural TEE demonstrated no evidence of tricuspid valve prolapse. (D) Postprocedural TEE revealed the severe TR on the midesophageal aortic valve short-axis view. (E) TTE at discharge demonstrated persistent severe TR on the apical 4-chamber view. (F) Retrospective review of intraoperative TEE after transcatheter VSR closure revealed partial tricuspid valve prolapse toward the right atrium. TEE = transesophageal echocardiography; TTE = transthoracic echocardiography; TR = tricuspid regurgitation; VSR = ventricular septal rupture.

Figure 5. Decision-Making Algorithm for the Management of Postinfarction Ventricular Septal Rupture ∗VA-ECMO alone may increase afterload and exacerbate left-to-right shunting; combination with other MCS devices should be considered. †Adequate rim and absence of myocardial hypertrophy should be confirmed to minimize ventricular interaction and ensure sufficient device expansion. AMI = acute myocardial infarction; ASD = atrial septal defect; IABP = intra-aortic balloon pump; MCS = mechanical circulatory support; VA-ECMO = venoarterial extracorporeal membrane oxygenation; VSD = ventricular septal defect; VSR = ventricular septal rupture.

Visual Summary. Transcatheter Closure of Post–Myocardial Infarction Ventricular Septal Rupture Using an Atrial Septal Defect Occluder In a frail elderly patient with postinfarction ventricular septal rupture (VSR) and cardiogenic shock, transcatheter closure was performed after delayed stabilization with appropriate mechanical circulatory support. Multimodality imaging confirmed adequate rim anatomy, allowing use of an atrial septal defect (ASD) occluder as an alternative to a dedicated VSD device. The procedure successfully reduced left-to-right shunting and improved hemodynamics. Key considerations include optimal timing with hemodynamic stabilization, careful anatomical assessment, and meticulous procedural technique to avoid complications such as tricuspid valve injury. IABP = intra-aortic balloon pump; TR = tricuspid regurgitation.