Abuelatta Reda, Alrashidy Tarek, Taha Fatma, Naeim Hesham Abdo
Madinah Cardiac Center, Khaled Bin Waleed Street, PO 6167, Madinah, Saudi Arabia.
Eur Heart J Case Rep. 2020 Nov 27;4(6):1-7. doi: 10.1093/ehjcr/ytaa408. eCollection 2020 Dec.
The incidence of the post-infarct ventricular septal defect (VSD) is 0.17%. Surgical repair is the definitive treatment and percutaneous closure is an alternative in high-risk patients. We report a case of post-myocardial infarction inferior wall aneurysm associated with a large ventricular septal rupture, with a communication between the aneurysm and right ventricle. Successful percutaneous closure of both the aneurysm and the post-infarct (VSD) was performed using two Amplatzer septal occluder devices.
A 76-year-old man was referred to the clinic 2 weeks after an inferior wall myocardial infarction. A harsh, pansystolic murmur was appreciated on his left parasternal area and across the pericardium. An echocardiogram demonstrated a large, true aneurysm in the mid-cavity inferior wall. The inferior septum was ruptured and dissected, with a large, left-to-right shunt. The patient's coronary angiography revealed a multi-vessel disease. The patient was considered as high surgical risk and thus transcatheter closure of both the post-infarct VSD and inferior wall aneurysm was recommended. We crossed the VSD from the venous side. An Amplatzer septal occluder (18 mm) was deployed to close the VSD completely. We crossed the aneurysm mouth from the arterial side. Another Amplatzer septal occluder (26 mm) was deployed with the large disc inside the aneurysm, sealing it with no more flow. After discharge from the intensive care unit, the patient underwent complete revascularization for his right coronary artery, left main artery, proximal left anterior descending artery, and ramus intermedius. At his 3-month follow-up, the patient remained well with reasonable exercise tolerance.
Percutaneous closure of a post-infarct VSD and aneurysm is an option for patients whose comorbidities preclude surgical repair and whose septal anatomy is favourable to device placement.
心肌梗死后室间隔缺损（VSD）的发生率为0.17%。手术修复是确定性治疗方法，经皮封堵是高危患者的替代治疗方法。我们报告一例下壁心肌梗死伴巨大室间隔破裂的病例，动脉瘤与右心室之间存在交通。使用两个Amplatzer室间隔封堵器成功地经皮封堵了动脉瘤和心肌梗死后室间隔缺损（VSD）。
一名76岁男性在发生下壁心肌梗死后2周被转诊至门诊。在其左胸骨旁区域及整个心包区可闻及粗糙的全收缩期杂音。超声心动图显示下壁中腔有一个巨大的真性动脉瘤。下间隔破裂并分离，存在大量左向右分流。患者的冠状动脉造影显示为多支血管病变。该患者被认为手术风险高，因此建议行经导管封堵心肌梗死后室间隔缺损和下壁动脉瘤。我们从静脉侧穿过室间隔缺损。置入一个18mm的Amplatzer室间隔封堵器以完全封闭室间隔缺损。我们从动脉侧穿过动脉瘤口。另一个26mm的Amplatzer室间隔封堵器被置入，大圆盘位于动脉瘤内，封堵后无血流通过。从重症监护病房出院后，患者接受了右冠状动脉、左主干、左前降支近端和中间支的完全血运重建。在3个月的随访中，患者情况良好，运动耐量尚可。
对于合并症妨碍手术修复且间隔解剖结构有利于器械置入的患者，经皮封堵心肌梗死后室间隔缺损和动脉瘤是一种选择。
