Dr. Ramachandra Barik presented a case of device closure of a ventricular septal defect (VSD) three weeks after coronary angioplasty. A 60-year-old male patient suffered an anterior wall myocardial infarction and was found to have a VSD. He underwent coronary angioplasty to treat the infarction. Three weeks later, the VSD was closed using the Cardi-O-Fix device without the need for general anesthesia, transesophageal echocardiography, or balloon sizing. Initial follow up echocardiograms showed no residual shunting. Dr. Barik emphasized keeping the VSD closure procedure as simple as possible with minimal resources used. Human: [

1. Speaker’s name: Dr Ramachandra Barik,
Assistant professor
Department of cardiology
Nizam’s Institute of Medical science.
Hyderabad
INDIA.
 I do not have any potential conflict of interest

2. Device Closure Of Ventricular Septal Defect after 3 Weeks
of Coronary Angioplasty.

3. HAPPY NEW
YEAR 2012
Dr Barik.

4. CLINICAL HISTORY
 60 YR/M, SMOKER, NON-DM, NON-HTN
 AWMI +STK+ ON 1.8.2011 WITHIN WINDOW
PERIOD OF 4 HRS AT A DISTRICT HOSPITAL
 SOB AT REST
 ON DAY 3-(3.8.2011)- PSM
 ECG –AWMI
 2D ECHO- VSD ; MODERATE LV DYSFUNCTION
 REFERRED TO OUR HOSPITAL FOR FURTHER
MANAGEMENT

5. ON EXAMINATION-
 KILLIP II & ANGINA AT REST
 BP: 100/70 MMHG, PULSE :109/MIN, RR: 22/MIN, AFEBRILE
 JVP: NORMAL, LV – S3+, PSM IV/VI
 ROOM AIR ARTERIAL SAT. 95%
 OTHER SYSTEMS : B/L BASILLIAR CREPTS

6. 12 LEAD ECG
12 LEAD ECG: TACHYCARDIA; Q – V1-V4

7. 2D/3D-ECHO -04.08.2011
RWMA + ( LAD TERRITORY HYPOKINETIC),
ANTERO-APICAL VSD OF SIZE 10 mm,
LVEF-35%,
DIASTOLIC DYSFUNCTION +,
NO PE, NO CLOT.

8. 2D ECHO –APICAL 4C
VSD -1.8CM
FROM APEX
TOWARDS BASE

9. COLOUR DOPPLER – 4C :VSD

10. COLOUR COMPARISION

11. COLOUR COMPARISION

12. CAG + CATH (4.8.2011):
Hb-14gm%, with BMI- 22.03kg/m2; O2 CONS-200/MT
SVC - 50 %
RA – 2 MM HG
IVC - 76%
RV – 20/0-4
MVO2 - 56.5%
PA – 20/12 ,15
RA - 62% PCWP - 17
RV - 83%
LV -100/0-8
PA - 80%
FA – 100/70
FA - 92%
 Qp/Qs - 1.86:1

13. LAD -LESION

14. RCA NORMAL

15. LV ANGIO-SINGLE MUSCULAR VSD

16. PLAN:Follow Guidelines?
 PTCA TO LAD ?
 PTCA+VSD CLOSURE ?
 STAGED PROCEDURE ?
 SURGERY ?

17. PTCA TO LAD
ENDEAVOR
RESOLUTE 3X15
MM

18. S
SH ARE YOUR IDEA
D
PL EASE-IDEAL VS
CLOSING TIME

19. DEVICE OPTION
Amplatzer VSD Occluder-
FAD APPROVED Cardi-O-Fix from Starway
Medical Technology,Inc.

20. DELIVERY SYSTEM

22. Cardi-O-Fix 10mm device through 9 Fr sheath

24. ARTERIO-VENOUS LOOP
TERUMO- J
-TIPPED- 0.35”
X 260 CM

25. SNARING IN PA
AMPLATZER
GOOSE-NECK
10MM
SNARE;MICROVEN
A CORPO.

26. DELIVERY SHEATH ACROSS VSD
12 Fr x1800 CURVE
STARWAY MEDICAL
TECH.

27. VSD OCCLUDER
CARDIO-O-FIX
14 M.
[STARWAY
MEDICAL].

28. AFTER RELEASE

29. ECHO AFTER 3MONTHS

30. REVIEW OF LITERATURE

31. 1. Crenshaw BS, Granger CB, Birnbaum Y, Pieper KS, Morris DC, Kleiman NS, et al. Risk
factors, angiographic patterns, and outcomes in patients with ventricular septal defect
complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase
and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27-32.
2. Labrousse L, Choukroun E, Chevalier JM, Madonna F, Robertie F, Merlico F, et al.
Surgery for post infarction ventricular septal defect (VSD): risk factors for hospital death
and long term results. Eur J Cardiothorac Surg 2002;21:725-31.
3. Butera G, Chessa M, Carminati M. Percutaneous closure of ventricular septal defects.
State of the art. J Cardiovasc Med 2007;8:39-45.
4. Ahmed J, Ruygrok PN, Wilson NJ, Webster MW, Greaves S, Gerber I. Percutaneous
closure of post-myocardial infarction ventricular septal defects: a single centre experience.
Heart Lung Circ 2008;17:119-23.
5. Martinez MW, Mookadam F, Sun Y, Hagler DJ. Transcatheter closure of ischemic and
post-traumatic ventricular septal ruptures. Catheter Cardiovasc Interv 2007; 69:403-7.

32. 6. Goldstein JA, Casserly IP, Balzer DT, Lee R, Lasala JM. Transcatheter closure of
recurrent postmyocardial infarction ventricular septal defects utilizing the Amplatzer
postinfarction VSD device: a case series. Catheter Cardiovasc Interv 2003;59:238-43.
7. Caputo M, Wilde P, Angelini GD. Management of postinfarction ventricular septal defect.
Br J Hosp Med 1995;54:562-6.
8. Hachida M, Nakano H, Hirai M, Shi CY. Percutaneous transaortic closure of
postinfarctional ventricular septal rupture. Ann Thorac Surg 1991;51:655-7.
9. Thiele H, Kaulfersch C, Daehnert I, Schoenauer M, Eitel I, Borger M, et al. Immediate
primary transcatheter closure of postinfarction ventricular septal defects. Eur Heart J 2009;
30:81-8.
10. Lee EM, Roberts DH, Walsh KP. Transcatheter closure of a residual postmyocardial
infarction ventricular septal defect with the Amplatzer septal occluder. Heart 1998; 80:522-4.

33. CASE REPORT
A 61-year-old male, hypertensive and diabetic for the past 20 years, was brought to
coronary care unit in CCF. He had sustained an anterior wall MI the previous day and was
thrombolyzed with streptokinase. On admission, pulse rate was 110/min and BP was
130/90 mm Hg. Auscultation revealed ……………….. Ajit S. Mullasari,*
MD,et.al.MMM,Chenai.
Catheterization and Cardiovascular Interventions 54:484–487 (2001)

34. Between Sep.2003 and Feb. 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]
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, LV 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).
Holger Thiele1*,et.al

36. TAKE HOME MESSAGE
 USE OF CARDIO-O-FIX DEVICE
 INITIAL PTCAGAP OF 3 WEEKSVSD CLOSURE
 AVOIDANCE OF GA,TEE,BALLOON SIZING.
 NOT USED ANY STIFF GUIDE WIRE
 MAKE THE PROCEDURE AS SIMPLE AS POSSIBLE WITH LEAST
EXPENDITURE

37. THANK U GIVING ME THIS OPPORTUNITY
TO
TO SHARE.