Case Reports

Transcatheter Closure of a Ventricular Septal DefectResulting From Knife Stabbing Using the Amplatzer

Muscular VSD Occluder

Colin Berry,1 PhD, MRCP, W. Stewart Hillis,1 MD, FRCP, and W. Brodie Knight,2* FRACP, FRCPCH

We report for the first time the transcatheter closure of a traumatic ventricular septaldefect (VSD) with the Amplatzer muscular VSD occluder in a 34-year-old man who hadbeen stabbed through the heart. After his initial life-saving surgery to relieve tampon-ade, control bleeding, and repair the lacerated right ventricle, the risks and difficultiesof subsequent open heart surgery were felt to favor transcatheter closure. We reviewother reports of transcatheter closure of traumatic VSD. ' 2006 Wiley-Liss., Inc.

Key words: transcatheter closure; traumatic VSD

INTRODUCTION

Cardiac trauma from penetrating injury is usuallyfatal, but in rare cases life may be saved by emergencysurgery. The morbidity and mortality from surgical re-pair of cardiothoracic trauma is considerable [1,2]. Wereport for the first time the successful transcatheter clo-sure of a traumatic ventricular septal defect (VSD) usingthe Amplatzer muscular VSD occluder (AmVSDO).

CASE REPORT

A 34-year-old man presented to the hospital withstab wounds to the left anterior chest. There had beenprofuse blood loss. Clinical examination revealed dis-tended neck veins, a blood pressure of 57/28 mm Hg,and a heart rate of 140 beats/min. Cardiac arrest subse-quently occurred. A left anterolateral thoracotomy wasperformed, which revealed hemorrhage from a trans-ected left internal mammary artery (LIMA) and a 2 cmlaceration of the right ventricular (RV) free wall. Theheart appeared to be collapsed and the wound appearedto involve the interventricular septum. Hemorrhage fromthe LIMA and RV free wall was controlled by digitalpressure until the LIMA and its side branches wereligated and the RV free wall closed. Subsequent echo-cardiography demonstrated a VSD measuring 10 mm 36 mm in the upper third of the septum. The peak leftto right shunt velocity was 4.8 m/sec and estimatedQp:Qs was 1.7. The patient was initially managed con-servatively, including treatment with intravenous anti-

biotics, and made good progress. Four weeks later, atoutpatient review he was breathless on mild exertionand echocardiography showed progressive LV enlarge-ment and estimated pulmonary artery systolic pressureof 40 mm Hg. The patient was then given the optionsof further surgery or transcatheter closure and chosethe latter.The procedure was attempted under general anaes-

thesia. Transesophageal echocardiography (TEE) re-vealed a defect 7 3 11 mm in diameter on the RV as-pect, 7 3 13 mm in diameter on its LV aspect, passingobliquely through the septum, with a tunnel length of14 mm (Fig. 1). Cardiac catheterization was performedusing the right femoral artery and vein and 10,000 IUof unfractionated heparin was administered. The VSD

1Department of Cardiology, Western Infirmary, Glasgow, Scot-land2Department of Cardiology, Royal Hospital for Sick Children,Glasgow, Scotland

Grant sponsor: University of Glasgow.

*Correspondence to: Dr W. B. Knight, Department of Cardiology,

Royal Hospital for Sick Children, Glasgow G3 8SJ, Scotland.

E-mail: brodie.knight@yorkhill.scot.nhs.uk

Received 12 August 2005; Revision accepted 30 January 2006

DOI 10.1002/ccd.20718

Published online 8 June 2006 in Wiley InterScience (www.interscience.

wiley.com).

' 2006 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 68:153–156 (2006)

was traversed (Fig. 2A) with a Terumo GlidewireTM

(TerumoMedical, Somerset, NJ) through a retrograde 4Fr Judkins right (JR) coronary catheter (Cordis, Miami,FL). The wire was passed into the pulmonary arteryfollowed by the JR catheter. A 300 cm long 0.03500

Amplatz Rope wire (AGA Medical, Golden Valley,MN) was substituted and snared with a 25 mmAmplatz ‘‘GooseneckTM’’ snare (Microvena, WhiteBear Lake, MN), which was then pulled out throughthe right femoral vein to form an arteriovenous loop.A 7 Fr Mullins-type sheath was passed over the wirethrough the VSD from the right side, allowing a 14mm AmVSDO (AGA Medical, Golden Valley, MN) tobe deployed in good position. However with only mildtension on the device, it pulled through to the RV sideand was removed. For want of further appropriateequipment, the procedure was cancelled and repeatedsuccessfully 4 months later using exactly the same tech-nique but with an 8 Fr sheath and 18 mm AmVSDO(Figs. 2B,C; 3). He received antibiotic cover with intra-venous cefuroxime 1.5 g, followed by a 28-day courseof clopidogrel (75 mg daily). Subsequently at outpatientreview at weeks 1 and 8, echocardiography confirmed awell-seated device, normal ventricular dimensions, nor-mal pulmonary artery systolic pressure (25 mm Hg), andno interventricular shunt. He is no longer symptomatic.

DISCUSSION

Although it is possible for a small traumatic VSD toclose spontaneously [3], this would have been veryunlikely in our patient whose symptoms and shunt sizeincreased insidiously over time. Transcatheter closureof either congenital [4,5] or acquired muscular VSDs

[4–7] is an emerging alternative to what is usually avery challenging surgical repair. While transcatheterclosure of VSDs arising after surgery [4,5] and aftermyocardial infarction [6,7] has been well described,transcatheter closure of post-traumatic VSD has onlybeen reported in five patients [8–12], the trauma beingpenetrating (knife stabbing) in only two [10,12]. Allwere closed with a similar procedure to that performedby us with creation of an arteriovenous loop. In thefirst case of blunt trauma [8], a VSD arose 8 weeks af-ter surgical repair of a left ventricular apical fissure(and 6 weeks after mitral valve replacement for papil-lary muscle rupture). An Amplatzer septal occluder(ASO) was successfully implanted under TTE control.The second case involved multiple injuries from amotorcycle accident [9] including a crush injury of thechest that resulted in two large muscular VSDs, bothmeasured by TEE and both closed with ASO devices.The mid-muscular device caused temporary completeheart block and the patient died of hypotension andmultiorgan failure 3 days after admission. The firstcase involving VSD after knife stabbing [10] initiallyunderwent surgical repair of the VSD with a Teflonpatch combined with tricuspid valve papillary musclerepair. There was subsequent patch dehiscence andheart failure. The defect was measured by angiographyto be 12 mm and a 12 mm AmVSDO was placed but,as in our first attempt, it fell through the defect andwas replaced with a 15 mm ASO with initially signifi-cant hemolysis but eventually only a tiny residualshunt, suggesting perhaps that even this device wassomewhat too small. As opposed to the ASO, the useof the AmVSDO allows use of oversized devices in asituation where it is difficult accurately to size the

Fig. 1. TEE assessment of the VSD immediately prior to transcatheter closure. a: Transgas-tric midpapillary short axis view showing VSD in the mid segment of the interventricular sep-tum. b: Long axis view illustrating the width of the VSD at the RV orifice to be 10.8 mm. [Colorfigure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

154 Berry et al.

defect [10] (which may initially be a linear laceration)without the bulging of the retention discs into the ven-tricular cavities that might occur with the ASO if thedefect is smaller than predicted. However for verylarge defects, especially those that may complicateblunt trauma, the largest AmVSDO (18 mm) may notbe large enough and either the ASO or the Amplatzerpostinfarct VSD occluder (with diameters from 18–24mm) may be the only alternative. Indeed in the secondcase of blunt trauma [11], two of the latter deviceswere used on consecutive occasions to attempt to close alarge apical VSD, but there remained a significant re-sidual shunt, again underlining the difficulty in assess-ing the true size of these defects, especially by angiog-raphy. In the final case, a smaller VSD resulting fromknife stab was closed with a similar technique usingan Amplatzer duct occluder [12]. The advantage of this

device was stated to be the lack of any RV retentiondisk that might have become caught up in tricuspidtensor apparatus, but equally there is the theoreticalrisk that it might fall out or work its way out into theLV cavity and embolize.Although conscious sedation is an attractive alterna-

tive, we believe that continuous TEE and simultaneousfluoroscopy allow for better assessment of defect posi-tion, morphology, and size and quicker and more accu-rate device implantation, release, and postrelease as-sessment especially when the position of the defect issuch that the device might cause outflow obstructionor impaired valve function. In view of the difficultiesof sizing such defects, our limited experience favorsthe use of an oversized AmVSDO unless contraindi-cated by proximity of tricuspid valve tensor apparatusor conduction tissues [9].

Fig. 2. TEE demonstrating transcatheter closure of the VSD. a: Four chamber view illustrating theTerumo wire across VSD. b: LV disc of AmVSDO extruded from the Mullins sheath into LV cavity. c:Long axis view of the deployed AmVSDO located in position high in the interventricular septum.[Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

Transcatheter Closure of a VSD 155

ACKNOWLEDGMENTS

We acknowledge Mr. Stuart Craig and Mr. ScottQueen for their emergency life-saving surgery on thesubject of this report, and Mr. Stuart Lilley for hisinvaluable echocardiographic expertise.

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Fig. 3. Confirmation of VSD occlusion: no left to right shuntis evident during contrast left ventriculography. Screw ofAmVSDO well seen on RV side of septum.

156 Berry et al.