Percutaneous Closure of an Iatrogenic Ventricular Septal Defect Following Concomitant Septal Myectomy at the Time of Aortic Valve Replacement
A 77-year-old female was diagnosed with severe AS and ABSH. On echocardiography, the patient showed a restriction of aortic cusp movement, raised trans-aortic peak instantaneous velocity of Vmax (5.93 m/s), mean pressure gradient of 80.49 mm Hg, peak pressure gradient of 140.56 mm Hg and a narrowed effective orifice area of 0.64 cm2. She also manifested moderate tricuspid regurgitation (TR) with a dilated tricuspid annulus and an elevated right ventricular systolic pressure (RVSP) of 56 mm Hg. Based on indications for surgery in AS, she underwent AVR using a 19-mm Carpentier-Edward valve (CE valve, Edwards Lifesciences LLC, Irvine, CA, USA) with concomitant septal myectomy and tricuspid annuloplasty (TAP), using a 28-mm Edwards MC3 (Edwards Lifesciences LLC, Irvine, CA, USA).\nAfter a successful operation, the patient complained of worsening dyspnea. On physical examination, a new continuous pansystolic murmur was noted. Echocardiogram demonstrated an abnormal high-velocity jet between the LVOT and right ventricle (RV) with a raised velocity of 4.78 m/s and peak pressure gradient of 91.33 mm Hg, suggesting the presence of a possible iatrogenic VSD (). The VSD was muscular in location, suggesting of complication by myectomy, not AVR in which it is usually present with membraneous type of VSD. The diameter of the VSD was about 12 mm, and the distance from the tissue aortic valve was about 1.5-2 cm. There was also an RV volume overload with moderate TR and an elevated RVSP of 61 mm Hg, despite the TAP. Medical treatments to maintain an optimal volume status was not effective, and the overall medical condition was poor. Therefore, a closure of the iatrogenic VSD with percutaneous intervention was decided, as it was felt to be hemodynamically significant.\nAt the right heart catheterization with the blood oximetry series to assess the degree of intra-ventricular shunting, there were remarkably elevated RV and pulmonary artery (PA) filling pressures, with an unidirectional left to right shunt of 2 : 1 (Qp/Qs=2).\nOn the 5th postoperative day, percutaneous closure of the VSD was attempted. It was decided that an attempt would be made to cross the VSD first from the RV (trans-septal technique). Left femoral artery and right femoral vein were punctured with 7 Fr sheaths. An LV angiogram showed a significant flow into RV cavity. Crossing of the VSD was made from the right side, using a 0.035-inch hydrophilic guidewire (angled straight tip, Terumo Medical, Tokyo, Japan) supported by a 5 Fr multipurpose catheter (Infiniti; Cordis, Miami, FL, USA), which was advanced into the LV apex. Then, the guidewire was replaced by a 0.035-inch extra-stiff guide wire (260-cm length, Amplatz Extra-Stiff, Cook, Bloomington, IN, USA). Then, a 14-mm Amplazter VSD occluder (AGA Medical Corporation, Golden Valley, MN, USA) attached to a delivery cable was advanced through the defect. The LV disc of the Amplazter VSD occluder was deployed first in the LV, and released the RV disc of the device in the RV by rotating the delivery cable in a counterclockwise direction (). An LV angiogram was performed confirming a minimal residual VSD flow, and intraoperative transesophageal echocardiogram demonstrated an excellent positioning of the device without shunting or any interference with aortic valve functions. At postprocedural catheterization, the PA pressure and saturation were decreased dramatically, from 50/15 mm Hg (mean 26 mm Hg), 91%, to 31/17 mm Hg (mean 23 mm Hg), 75%. Postprocedural echocardiogram showed a minimal shunt between the LVOT and RV without LVOT obstruction ().