A 76 year-old female smoker was thrombolyzed with Tenecteplase after an acute anterior myocardial infarction. Unfortunately she remained hypotensive and so she underwent emergency angiography which showed patent coronary arteries except for the left anterior descending artery which was occluded distally. After this procedure she was noted to have a pansystolic murmur and transthoracic echocardiography (TTE) using a Vivid 7 Pro (GE Vingned, Norway), confirmed a 1 cm antero-apical VSD and an akinetic ventricular apex.
To manage her hypotension inotropes were commenced and an intra-aortic balloon pump was inserted. After stabilization for 5 days, diuretics and nitrates were added for progressing pulmonary oedema. Repeat TTE images showed no change, and although the right ventricle was mildly dilated, global left ventricular function was preserved. A decision was made to perform a delayed surgical repair to reduce operative risk.
She was reviewed in the local multi-disciplinary meeting and transcatheter closure was not thought to be appropriate. Four weeks after admission, she developed short episodes of ventricular tachycardia which were controlled by amiodarone. Two days later she deteriorated becoming hypotensive with worsening pulmonary oedema. She became hypoxic and hypercarbic and dobutamine infusion was added along with an escalation in her diuretic therapy. Sedation and mechanical ventilation were then required. Repeat TTE remained unchanged. A pulmonary artery flotation catheter was inserted and norepinephrine was commenced to treat persistent hypotension. Renal function began to deteriorate with serum creatinine rising to 190 μmol l-1.
Thirty days after myocardial infarction, she underwent an off-pump 'Hamburger' post-infarct VSD repair. The heart was approached through a median sternotomy and a posterior-anterior septal plication was performed using three double-armed Teflon felt supported interrupted 1.0 Ticron sutures (Syneture™, USA). The Teflon strip was preloaded with sutures and from below the needles were passed through the posterior (inferior) interventricular septum aiming for the anterior part of the septum where the tip of the needle is retrieved. The sutures run just lateral to the LAD to ensure plicating the thicker left ventricular wall rather than the thinner right ventricular wall (Figure 1). The needles were then passed through the second Teflon strip and then tied starting at the apex and working more proximally (Figure 2). VSD closure was assessed using transesophageal (Figure 3) and epicardial echocardiography as well and by epicardial auscultation.
Soon after surgery, she began to improve and her inotropes and frusemide were discontinued. However she required a tracheotomy to facilitate weaning from mechanical ventilation. She was transferred to a rehabilitation facility 4 weeks after the operation. She was found to be asymptomatic and mobilising independently at 6 month follow-up.