Deployment of ASD Device

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Deployment of ASD Device

VSR/Arora/2008Transcatheter Closure of PostMyocardial InfarctionVentricular Septal RuptureR. Arora & P. LalMetro Hospitals & Heart InstituteNoida & Delhi, India


VSR/Arora/2008POST MI - VSR• Incidence: 2% of 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. of patients = 20• Age range (in years) = 42 – 73• Sex ratio (male / female) = 8 / 12• Cardiogenic shock = 8 (40%)• Site of Infarct Anterior = 14 (70%)Inferior = 6 (30%)• CAG Single Vessel Disease = 14 (70%)Multi Vessel Disease = 6 (30%)Coronary Angioplasty of 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 Device = 2 (10.5%)• Surgical closure = 1 (5.25%)• Mortality = 7 (35%)


POST MI - VSRVSR/Arora/2008MORTALITY (N = 7 , 35%)• Days of presentation = 3 to 18• Age in years= 55 to 73 (M62)• Sex male / female = 2 : 5• Site of infarctionAnterior = 4 (28%)Inferior = 3 (50%)• IABP Support = 3 (37.5%)• LVEF (%) = 22 to 35• Cause of deathCirculatory failure = 4 (57%)Renal failure = 3 (43%)


POST MI - VSRVSR/Arora/2008RESIDUAL SHUNT N = 6 (31.5%)ApicalVSRWithDeviceandL-Rshunt


POST MI - VSRVSR/Arora/20082Two Devices 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 of Days2 to 4 5 to 14 15 to 60• No. of patients (%) 50 25 25• Survival (%) 60 60 80• Mortality (%) 40 40 20Circulatory failure (%) 75 - 25Renal failure (%) 25 100 -


POST MI - VSRVSR/Arora/2008AuthorsDevice 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 of VSR underwent transcatheter closure after 2 to 60day of acute MI (Ant. 14, Inf. 6)• 8 patients were in cardiogenic shock and IABP assistance wasused• All had PTCA of Infarct related artery and one of 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 of 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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