A staged approach to a challenging case of interventricular septum rupture

Current guidelines of the American College of Cardiology- American Heart Association for the treatment of postinfarction VSD recommend immediate surgical repair, regardless of clinical status (class I recommendation).

Multiple series emphasized the importance of early surgical repair, but the ideal timing of the intervention is still a matter of debate.

Thus, the treatment and the correct management of patients presenting with VSD after acute MI is still a subject of interest, especially in the era of evolving technologies.

Ventricular assist device placement provides hemodynamic support for patients who are in cardiogenic shock from a postinfarction VSR. Support from this device creates a therapeutic window during which the patient can recover before surgery and provides extra time to plan the optimal repair technique, both of which can help avoid a residual shunt.

Background

Clinical presentation

• Female 60 yrs, 50 kg x 152 cm• Ascending aortic replacement for acute

aortic dissection type II De Bakey in 2004• Extensive antero-septal MI persistent after

trombolysis (Troponine T >102 ng/dl)• Emodinamic instability: low AP, oliguria,

tachycardia, anxiety• Referred to a tertiary care center

Instrumental investigation

• Coronary catheterization findingsOcclusion in the middle tract of DA

• Echo findingsNormal LV dimensions, Low EF 30%, antero-septal aneurysm, E/A restrictive patternDilated hypocontractile RV, RVPs 52mmHg, TAPSE 12 mm, dilated IVCTwo IVSRs the bigger one of about 1 cm2 with leftright shunts

Choosing the treatment...• Surgical repair of IVSR was considered very high risk• Clinical stabilization with medical therapy and IABP-despite

previous history of aortic dissection because of the favorable anatomy (type II De Bakey) and the drammatic conditions

• Hemodinamic procedure with Amplatzer device to close the bigger IVSR or Delayed Surgery after myocardial Recovery.

What really happened...After 48 hrs of IABP and iv dobutamine -> clinical

worsening:• Reduction of consciousness• Anuria• Peripheral vasoconstirction• Jugulars and Liver Congestion• Diffused thoracic rumors

Echocardiogram: a third hole in the apical septum appears

Evolving infarction of the septal miocardium with increase in leftright shunt

No more indicaton for a hemodinamic procedure

...and what was effectively done

Implantation of a peripheric ECMO

(left femoral vein-> left femoral artery)

as bridge to recovery or to transplantation

ECMO course96 hrs on mechanic circulatory support• Surgical revision for bleeding• 4 RBC - No other emoderivatives• After 13 Hours estubated • Echo was showing no improvement in

LV nor RV function• On the 5° day: left leg malperfusion->

augmented heparin infusion• On the 5° day Transplantated with

emergency criteria (Status I)

Transplantation course• Resternotomy assisted by institution of CPB with

the ECMO cannulae than Bicaval-femoral artery cannulation on total hypotermic CPB

• Emoderivatives consumption: 10 platlet,4 FPC,6 RBC (of which 2 on CPB)

• After 24 hrs estubated• Recovery of diuresis after 24 hrs of CVVH and

normalization of renal parameters after 8 days infusion of Fenoldopam 0.1 γ/kg/min

• Total ICU stay lenght: 10 days• Discharged on the 28° postoperative day• Complete recovery of the ischemic neurologic

damage of the left leg with a institutional rheabilitation program

• Now on NYHA I after 6 months follow-up. No complications occurred

ConclusionsECMO implantation may be an eccellent way to stabilize IVS rupture and bridge it to a successfull surgery whenever surgery is feasible or to Heart Transplantation if surgery carry a prohibitive risk.

Case in which recovery of a sufficient myocardial function is unlikely should also be considered for such a strategy.