Harshbir S. Pannu, Mch.1, Puneet Verma, DM2, Radha Krishanan, DM3.
1Batra Hospital & Research centre, New Delhi, India, 2Prime Heart Institute, Chandigarh, India, 3Escorts Heart Institute & Research centre, New Delhi, India.
OBJECTIVE: Ventricular septal rupture (VSR) following myocardial infarction (MI) is a rare but disastrous complication needing urgent surgical intervention. In high risk situations open patch repair carries upto 50% mortality. Trans catheter closure too carries suboptimal results.
METHODS: A Sixty year old hypertensive male presented with acute inferior and right ventricle MI with inter ventricular septal rupture, complicated by cardiogenic shock and anuria. Echo revealed a dissecting type III septal rupture of 18 mm size, capped by an aneurysm on the right ventricle aspect with LVEF of 30% & RVEF of 25%. Patient was managed aggresively with IABP & ionotropes till the urine started flowing. Immediate Cardiac catheterisation & coronary angio revealed critical tripple vessel disease with severe PAH and Qp/Qs of 2.7:1. He was advised urgent surgery but the risk of conventional open repair was unacceptable to the family. The approach was thus modified since he continued to be in congestive heart failure and NYHA IV. After off-pump tripple coronary bypass the point of maximal thrill using finger and TEE was localised on the anterior right ventricle surface. Through pledgetted purse string suture, a 9Fr. vascular sheath was inserted using seldinger technique across the VSR. Then a 20 mm. muscular occluder device was placed across the VSR, which inadvertently got deployed in the aneurysm, but abolished the major shunt.
RESULTS: He made an uneventful recovery and was discharged on the 9th postoperative day. Serial echoes reveal a stable device position with trivial shunt. At 18 mths folloow up he is in NYHA I, with LVEF of 50% & RVEF of 30%.
CONCLUSIONS: Appropiate patient and device selection along with refinements in hardware is likely to smoothen and standardise this hybrid approach in high risk patients.
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