Immediate primary transcatheter closure of postinfarction ventricular septal defects

Abstract

Immediate surgical repair of ventricular septal defect (VSD) complicating acute myocardial infarction is associated with high mortality. Percutaneous device closure appears to be safe and effective in patients treated for a residual shunt after initial surgical closure, as well as in patients with a chronic post-infarct VSD. Primary transcatheter VSD closure in the acute setting may also offer advantages over surgery. Between September 2003 and February 2008, 29 consecutive patients underwent primary transcatheter VSD closure. Clinical, procedural, and outcome data were collected. Patients were divided into those with and those without cardiogenic shock at presentation for risk stratification. The median follow-up time of surviving patients was 730 days. The median time between VSD occurrence and closure was 1 day [interquartile range (IQR) 1-3] and the initial procedural success rate was 86%. The shunt (Qp:Qs) could be reduced from 3.3 (IQR 2.3-3.8) to 1.4 (IQR 1.2-1.7; P < 0.001). Procedure-related complications such as major residual shunting, left ventricular rupture, and device embolization occurred in 41%. The overall 30-day survival rate was 35%. Mortality was higher for cardiogenic shock in comparison to non-shock patients (88 vs. 38%, P < 0.001). Interventional acute VSD closure is a promising technique that can be performed with a high procedural success rate and may offer an alternative to surgery. Despite the less invasive technique, mortality of postinfarction VSD remains high, particularly in patients with cardiogenic shock. Further developments in devices and delivery techniques are required.