Deployment of ASD Device
Deployment of ASD Device
Deployment of ASD Device
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VSR/Arora/2008Transcatheter Closure <strong>of</strong> PostMyocardial InfarctionVentricular Septal RuptureR. Arora & P. LalMetro Hospitals & Heart InstituteNoida & Delhi, India
VSR/Arora/2008POST MI - VSR• Incidence: 2% <strong>of</strong> AMI have VSR in clinical series(Held et al, 1988)• After thrombolysis incidence is 0.2%, but early within16 hours (GUSTO-I, Circulation, 2000)• 30-day mortality despite intensive medical therapy is80 - 90% (GUSTO-I)• Potentially fatal once cardiogenic shock sets in• Death is usually not immediate: Early aggressiveapproach is very important• ACC/AHA recommends early aggressive surgery(CABG) + VSR repair• Not all candidates are suitable due to hypotension andCHF (compromised situation)
POST MI - VSRVSR/Arora/2008MATERIAL AND METHODS• Total No. <strong>of</strong> patients = 20• Age range (in years) = 42 – 73• Sex ratio (male / female) = 8 / 12• Cardiogenic shock = 8 (40%)• Site <strong>of</strong> Infarct Anterior = 14 (70%)Inferior = 6 (30%)• CAG Single Vessel Disease = 14 (70%)Multi Vessel Disease = 6 (30%)Coronary Angioplasty <strong>of</strong> Infarct related Artery for all& one had primary PTCA prior to VSR
POST MI - VSRVSR/Arora/2008PRIMARY PTCA OF LAD
POST MI - VSRVSR/Arora/2008SITE OF VSR RUPTUREApicalMidMuscular•Apical - 6 (30%)•Mid muscular - 9 (45%)•Basal - 5 (25%)Basal
POST MI - VSRVSR/Arora/2008APPROACH TO VSR CLOSUREFrom LV SideFrom RV Side10 patients 9 patientsCatheter : Swan Ganz, Judkin’s Right, MultipurposeWire : Terumo, Rarely PTCA wire
POST MI - VSRVSR/Arora/2008VSR DEFECT CROSSED WITH TERUMO WIRE IN AORTA
POST MI - VSRVSR/Arora/2008VSD DEVICE THROUGH DELIVERY CATHETER IN LV
POST MI - VSRVSR/Arora/2008DISTAL DISC OF VSD DEVICE OPENED IN LV
POST MI - VSRVSR/Arora/2008LV ANGIO WITH DISTAL DISC IN POSITION
POST MI - VSRVSR/Arora/2008LV ANGIO SHOWING RESIDUAL SHUNT
POST MI - VSRVSR/Arora/20083D ECHO SHOWING VSD DEVICE IN POSITION
POST MI - VSRVSR/Arora/2008RESULTS (N = 19)• Successful device deployment = 19 (100%)• Complete occlusion = 13 (68.5%)• Residual shunt = 6 (31.5%)• Second <strong>Device</strong> = 2 (10.5%)• Surgical closure = 1 (5.25%)• Mortality = 7 (35%)
POST MI - VSRVSR/Arora/2008MORTALITY (N = 7 , 35%)• Days <strong>of</strong> presentation = 3 to 18• Age in years= 55 to 73 (M62)• Sex male / female = 2 : 5• Site <strong>of</strong> infarctionAnterior = 4 (28%)Inferior = 3 (50%)• IABP Support = 3 (37.5%)• LVEF (%) = 22 to 35• Cause <strong>of</strong> deathCirculatory failure = 4 (57%)Renal failure = 3 (43%)
POST MI - VSRVSR/Arora/2008RESIDUAL SHUNT N = 6 (31.5%)ApicalVSRWith<strong>Device</strong>andL-Rshunt
POST MI - VSRVSR/Arora/20082Two <strong>Device</strong>s used1•ASO 24mm•VSD occluder – 14mm
POST MI - VSRPROGNOSTIC INDICATORSMortalityVSR/Arora/2008Survival• Age in years (median) 62 51• Sex male / female 1:2.5 1:1.1• Anterior vs Inferior 28:50 72:50• IABP Support (%) 37.5 62.5• LVEF (%) 28+6 35+9
POST MI - VSRVSR/Arora/2008DAYS OF PRESENTATIONNumber <strong>of</strong> Days2 to 4 5 to 14 15 to 60• No. <strong>of</strong> patients (%) 50 25 25• Survival (%) 60 60 80• Mortality (%) 40 40 20Circulatory failure (%) 75 - 25Renal failure (%) 25 100 -
POST MI - VSRVSR/Arora/2008Authors<strong>Device</strong> No. Success RemarksLock et al RUD 4 3(75%) Temporary palliation(1988)Benton et al RUD 1 1(100%) Definitive therapy poor(1992) risk surgical candidatesLandzberg RUD 7 7(100%) 3 patients survived(1998)Walsh et al ASO 11 10(100%) 7 survived & 1 had(2004) VSD surgical repairIbrahim et al ASO 6 6(100%) 4 Definitive therapy(2004) VSD 2 bridge to surgeryRam et al CABG 20 16(80%) 65% survived &(2002) & VSR 1 device closure
POST-MI VSRVSR/Arora/2008SUMMARY• 20 patients <strong>of</strong> VSR underwent transcatheter closure after 2 to 60day <strong>of</strong> acute MI (Ant. 14, Inf. 6)• 8 patients were in cardiogenic shock and IABP assistance wasused• All had PTCA <strong>of</strong> Infarct related artery and one <strong>of</strong> them hadprimary PTCA prior to VSR• Procedure attempted in 19 patients was successful in all but 6(32%) had residual shunt, (second device was given in 2 &surgical repair in 1)• Mortality was 35%, more in females, inferior MI and those whopresented within first 96 hours• Survival was better with anterior MI in younger patients and inmales• 62.5% in cardiogenic shock could be salvaged with IABP support
POST MI - VSRVSR/Arora/2008CONCLUSIONS• This approach may not necessarily produce thebest results for the entire group <strong>of</strong> patients butis an important therapeutic option along withCoronary Angioplasty for these acutely illpatients who are otherwise high risk surgicalcandidates• An early aggressive approach can salvage morepatients
VSR/Arora/2008ThankYou
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