Case Report
A 50 years-old male without cardiovascular risk factors was admitted with acute inferior myocardial infarction for which he underwent percutaneous coronary intervention (PCI) with implantation of two drug-eluting stents, one in the right coronary artery and the other in the obtuse marginal. After the procedure the patient remained hemodynamicaly unstable. His transesophageal echocardiography (TEE) showed left ventricular ejection fraction (LVEF) of 40%, moderate mitral regurgitation, inferobasal aneurysm and a large muscular VSR in the infero-posterior septum (Figure 1). He was supported with intra-aortic balloon pump and underwent coronary artery bypass graft, bovine pericardial patch VSR closure and mitral valve replacement. Four days later, he was found to have a residual ventricular rupture (Figure 2) which made him symptomatic again. In view of his clinical conditions (NYHA class III), it was decided to address his recurrent VSR using a catheter-based technique. The patient was consented after the local ethics committee and the local regulatory agency have approved the use of the device. The PIVSR was crossed from left to right ventricle using a retrograde arterial approach (left femoral artery) with a 5F multipurpose catheter and a Terumo wire that was advanced into the inferior vena cava, where it was snared via the right femoral vein establishing an arteriovenous rail (Figure 3). The 18,6 mm residual VSR was closed using a newly designed custom-made occluder (PIVSD device, Occlutech® Holding AG, Switzerland) (Suppl Figures 1-3), not CE marked yet, therefore available for compassionate use only. The requesting physician needs to fill and sign a prescription letter, obtain local Ethics Committee approval and get permission from national authorities.
The waist size of the occluder was 7 mm larger than the VSR size. The device consists of two self-expanding oval-shaped discs (left 36 mm, right 34 mm) composed of a nitinol-wire mesh with “shape-memory” properties joined together by a flexible elliptical waist 10 mm in length and 24 mm in diameter. Thin non-woven polyethylene terephthalate (PET) patches are sutured into both discs and into the inside of the waist to ensure rapid sealing of the defect while optimizing ingrowth of tissue. The procedure was performed under general anesthesia with fluoro-angiography and TTE guidance. The occluder was placed at the appropriate site across the rupture and then released. The device was stable and there was a tiny residual shunt immediately after device implantation. The patient made an uneventful recovery and was discharged after 12 days. At dismission TTE confirmed stable position of the device with trivial residual left-to-right shunt (Figure 4). At 12-month follow-up the patient remained symptom free. TTE confirmed stable position of the device with no left-to-right shunt, mild left ventricular dysfunction and normal function of the mitral prosthesis.