Transcatheter closure of left ventricular free wall rupture with Amplatzer atrial septal defect occluder

Abstract

Left ventricular free wall rupture is a dramatic complication of acute myocardial infarction and is presumably responsible for as much as 20–30 % of all infarct-related deaths [1]. Surgical management is essential [2]. Needle pericardiocentesis is the conventional treatment of cardiac perforation [3]. A 79-year-old man in evolving cardiogenic shock (BP 70/40) mmHg, sinus tachycardia (120 beats/ min) was transferred to our regional cardiac center. ECG showed ST-segment elevation in II, III, aVF and V4–6 leads. Emergency coronary angiography was performed, and totally occluded obtuse marginalis and nonsignificant stenosis in others coronary arteries were detected (Fig. 1a). Bedside transthoracic echocardiography (TTE) revealed LV regional wall motion abnormality and cardiac tamponade. Cardiac rupture was detected at the LV apex. TTEguided pericardiocentesis was performed immediately. However, there was no drainage from the catheter. Hemoglobin decrease was approximately 4 mg/dL during this time. We have decided to try percutaneous closure due to lack of 7/24 surgical backup. The procedure was applied in order to gain time; as a bridge for surgery. The procedure was an emergency and the defect size was only measured with transthoracic echo and a standard Amplatzer TorqVue delivery system was used through a 7F sheath. A 10, 5-mm Amplatzer occluder (Amplatzer occluder is from St. Jude Medical) was deployed (Fig. 1b). The operation was finished in 15 min. A subsequent TTE showed the defect was successfully occluded with only a trivial residual leak (Figs. 2a, 3). The patient slightly recovered after the procedure, blood pressure could be recorded but he was still in cardiogenic shock due to the impossibility of removing the agglutinant pericardial effusion. Therefore, the patient was transferred to the operation room (Fig. 2b). A large haemorrhagic pericardial effusion was seen and the entire heart was covered in a thick fibrinous peel. But he died 6 h after the initial chest pain. This case confirms that transcatheter closure of ventricular free wall rupture with an occluder device is a bailout strategy in very skilled centers for selected cardiogenic shock patients in the absence of on-site cardio-thoracic support.