3D transesophageal echocardiography is a decision-making tool for the management of cardiogenic shock following a large postinfarction ventricular defect.

Yihua Liu,Jean-Pierre Villemot,Christine Selton-Suty,Pablo Maureira,Olivier Huttin,Zied Frikha,Bruno Levy

doi:10.1186/s13019-015-0208-y

Abstract

Postinfarction ventricular septal defect (PIVSD) is a devastating mechanical complication following acute myocardial infarction. The management of this pathology is quite challenging, especially in case of complicated cardiogenic shock. The difficulties lie in the timing and type of intervention. Debates exist with regard to immediate versus deferring repair, as well as open repair versus percutaneous closure. The anatomic characteristics and hemodynamic consequence of PIVSD are important elements determining which strategy to adopt, since large septal defect (>15 mm) cannot be appropriately treated by percutaneous occluder devices limiting by their available size, while compromised hemodynamics usually require emergent repair or mechanical support “bridging to surgery”. Herein, we report our experience of successful management of a case of cardiogenic shock complicating large PIVSD (38 mm) by delayed surgical repair bridged with Extracorporeal Membrane Oxygenation (ECMO) during 7 days. We emphasize the importance of 3-dimensional transesophageal echocardiography as a decision-making tool.

Highlights

Postinfarction ventricular septal defect (PIVSD) is a lifethreatening mechanical complication of acute myocardial infarction with a declining incidence but a poor prognosis
The classic dilemma of the management of PIVSD is the timing of intervention: most of the patients require an emergent repair to improve hemodynamics, while intentional deferment of intervention allows reducing the risk of residual shunt through organization and fibrosis of the frail infarct tissue
The evolving percutaneous closure technique is attractive in this critical condition, which can be performed as an alternative of or bridge to surgical repair

Summary

Background

Postinfarction ventricular septal defect (PIVSD) is a lifethreatening mechanical complication of acute myocardial infarction with a declining incidence but a poor prognosis. Another transthoracic echocardiography with Doppler color flow revealed a high-velocity left-to-right ventricular shunt suggesting a PIVSD (Figure 1D). The two-dimensional (2D) TEE identified a large VSD (Figure 1D) and a mild mitral regurgitation, Qp/Qs was calculated to be 2.8. As the initial 2D morphological findings were insufficient to comprehend the relationship between the defect and the surrounding structures, we performed real-time three-dimensional (3D) TEE images to acquire detailed findings with regard to the size, the shape and the relationship with surrounding tissue, which confirmed an anterial muscular septal defect measuring 27*38 mm (Figure 1E, F), and revealed a mild mitral valve regurgitation, without papillary muscle tearing nor mitral chordae rupture being detected. As the hemodynamics was maintained with ECMO, a semi-elective operation was performed 7 days following initial mechanical support. The recovery was uneventful and the patient was doing well 6 months later with NYHA class II

Discussion

Conclusion