OPINION Amplatzer Post-Infarction Ventricular Septal Defect Closure via Retrograde Transarterial Access: Easier and Better David Hildick-Smith, MD a , Natalia Briceno, MDRes, MRCP a , Osama Alsanjari, MRCP b , Gerald J. Clesham, PhD FRCP b , Thomas Keeble, MD b , Andrew Hill, FRCA, FFICM a , Arionilson Gomes, BSc a , and James Cockburn, MD a a Department of Cardiology, Sussex Cardiac Centre, Brighton, UK; b Department of Cardiology, Essex Cardiothoracic Centre, Basildon, UK ARTICLE HISTORY Received 10 August 2020; Revised 29 November 2020; Accepted 23 December 2020 Introduction Percutaneous closure of postinfarction ventricular septal defect (PIVSD) after myocardial infarction is one of the most demanding interventional procedures. Patients are usually hemodynamically brittle and the stakes are high – failure to close the defect successfully usually results in death. The procedure is normally done under general anesthesia with transesophageal echocardiography (TEE) guidance, using an arteriovenous circuit. This circuit is created from the left ventricle to the right ventricle – locating the defect from the right side is difficult, and crossing with the flow of blood is usually more straightforward. Snaring the crossing wire in the pulmonary artery is standard, and a full arteriovenous circuit is made, though there is a risk of entrapment of tricuspid valve chordae, in which case the snaring procedure must be repeated. Once a full arteriovenous circuit is made, delivering the Amplatzer PIVSD device from the venous side is not neces- sarily easy. Crossing the defect with the delivery sheath places strain on an already weak and raw septum; hemodynamics can be unstable, and alignment with the septal rupture may be poor, particularly as the sheath is withdrawn. Successful clo- sure of the defect is only achieved in 23% of cases. 1 Mindful of these limitations, and following a number of cases with disappointing results, we have been using a retrograde arterial approach, rather than a venous approach via an arteriovenous circuit. Using this method, we have had technical procedural success with five cases out of five, although only two of five patients survived. We present the case series here and discuss the advantages of arterial delivery of the Amplatzer device. All patients included in this case series underwent full informed consent for their clinical pro- cedure. Due to the case series nature of this report, there was no requirement to have our institutional review board approve this study. Historical perspective Historically, percutaneous VSD closure has been mostly taught via an arteriovenous circuit with the device delivered from the venous side. Purely arterial access has also been used, albeit only exceptionally. 2 There are a number of rea- sons for a predominant venous route. Firstly, large bore sheaths (10 F, 12 F) are required, and until the last decade, methods to close arterial access of this caliber were poorly catered for. Risks of major vascular complications were high. Secondly, sheaths were not braided and kink-resistant until the last decade such that left ventricle to pulmonary artery crossing risked sheath kinking with resulting difficulty in device delivery. Third, large bore sheaths of the necessary length (usually >100 cm) have not been widely available. Fourth, pediatric practice informed adult practice with regard to VSD closure, and the venous delivery route was the default approach among pediatric cardiologists when dealing with congenital ventricular septal defects. Case series Case 1 A 52-year-old lady was admitted to a district hospital with a late presentation inferior myocardial infarction. She was found to have a loud systolic murmur, and on echocardio- graphy, an interventricular septal rupture was seen. She was transferred to the Sussex Cardiac Center and underwent emergency surgical repair. However, she became increasingly unwell with jaundice, hypotension, impaired renal function, and impaired consciousness. Her echocardiogram demon- strated partial dehiscence of the patch with a residual leak. We, therefore, arranged for attempted salvage percutaneous repair. The patient’s first procedure was done in a standard man- ner using an arteriovenous rail. Under anesthesia and, with TEE guidance, the interventricular septum was crossed with a long pigtail catheter. A Terumo Glidewire was then passed into the right atrium and then inferior vena cava (rather than pulmonary artery) in order to avoid the potential for tricuspid valve chordal entrapment. The pigtail was snared in the infer- ior vena cava. The Glidewire was removed and a 260 cm Noodle Wire was inserted, snared, and withdrawn through the right femoral vein, forming an arteriovenous rail. A 10 F 80 cm sheath was passed across the defect from the right femoral vein, tenting the septum a little as it passed, and CONTACT David Hildick-Smith [email protected] Deptartment of Cardiology, Brighton and Sussex University Hospitals NHS Trust, Brighton, BN2 5BE, UK. STRUCTURAL HEART 2021, VOL. 5, NO. 3, 263–268 https://doi.org/10.1080/24748706.2021.1894371 © 2021 Cardiovascular Research Foundation
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