Percutaneous closure of an iatrogenic ventricular septal defect following concomitant septal myectomy at the time of aortic valve replacement

Abstract

A 77-year-old female patient underwent aortic valve replacement (AVR) with concomitant septal myectomy and tricuspid annuloplasty. Her symptoms did not improve after a successful operation. Echocardiogram demonstrated the presence of an iatrogenic ventricular septal defect (VSD). It was muscular in location and not the usual AVR with membraneous type of VSD, suggesting a complication from the myectomy. Percutaneous closure of the VSD remained the only feasible option due to her poor overall medical status. A 14-mm Amplazter VSD occluder was deployed successfully, by means of the trans-septal technique. She has improved very well postoperatively.

Keywords: Heart septal defects; Septal occluder device.

Fig. 1

Iatrogenic VSD assessment by echocardiography. A: parasternal long-axis view shows a muscular VSD (arrow), suggesting of a complication by myectomy, not AVR in which it is usually present with membraneous type of VSD. B: color Doppler imaging depicts a high-velocity jet between the left ventricle and right ventricle. C: the velocity and peak pressure gradient across the defect are measured at 4.78 m/s and 91.33 mm Hg, respectively. VSD: ventricular septal defect, AVR: aortic valve replacement, RV: right atrium, LV: left ventricle, Ao: aorta.

Fig. 2

Placement of Percutaneous Amplatzer Muscular ventricular septal defect (VSD) occluder. A: a 0.035 inch extra-stiff guide wire (arrow) is advanced from the femoral vein through the defect, and into the left ventricle (LV) apex. B: the diameter of Amplazter VSD occluder is measured using an Amplazter sizing balloon II (arrow). C: the LV disc of the Amplazter VSD occluder (arrow) is deployed first in the LV. D: it has released the right ventricle (RV) disc of the device (arrow) in the RV by rotating the delivery cable in a counterclockwise direction.

Fig. 3

Post-procedural echocardiography. A: parasternal long axis view shows the appropriate positioning of the Amplazter ventricular septal defect occluder. The device is seen as a dense crescent-like structure (arrow), at the left side of the interventricular septum. The left ventricular outflow tract is not obstructed. B: color Doppler imaging shows near-elimination of the left to right shunt after device delivery. RV: right ventricle, LV: left ventricle, LA: left atrium, Ao: aorta.