1. A staged approach to a challenging case of
interventricular septum rupture

2. Background
Current guidelines of the American College of Cardiology- American Heart
Association for the treatment of postinfarction VSD recommend immediate
surgical repair, regardless of clinical status (class I recommendation).
Multiple series emphasized the importance of early surgical repair, but the ideal
timing of the intervention is still a matter of debate.
Thus, the treatment and the correct management of patients presenting with
VSD after acute MI is still a subject of interest, especially in the era of evolving
technologies.
Ventricular assist device placement
provides hemodynamic support for
patients who are in cardiogenic shock
from a postinfarction VSR.
Support from this device creates a
therapeutic window during which the
patient can recover before surgery and
provides extra time to plan the optimal
repair technique, both of which can help
avoid a residual shunt.

3. Clinical presentation
• Female 60 yrs, 50 kg x 152 cm
• Ascending aortic replacement for acute aortic
dissection type II De Bakey in 2004
• Extensive antero-septal MI persistent after
trombolysis (Troponine T >102 ng/dl)
• Emodinamic instability: low AP, oliguria,
tachycardia, anxiety
• Referred to a tertiary care center

4. Instrumental investigation
• Coronary catheterization findings
Occlusion in the middle tract of DA
• Echo findings
Normal LV dimensions, Low EF 30%, antero-septal aneurysm,
E/A restrictive pattern
Dilated hypocontractile RV, RVPs 52mmHg, TAPSE 12 mm, dilated IVC
Two IVSRs the bigger one of about 1 cm2 with leftright shunts

5. Choosing the treatment...
• Surgical repair of IVSR was considered very high
risk
• Clinical stabilization with medical therapy and
IABP-despite previous history of aortic dissection
because of the favorable anatomy (type II De
Bakey) and the drammatic conditions
• Hemodinamic procedure with Amplatzer device to
close the bigger IVSR or Delayed Surgery after
myocardial Recovery.

6. What really happened...
After 48 hrs of IABP and iv dobutamine -> clinical worsening:
• Reduction of consciousness
• Anuria
• Peripheral vasoconstirction
• Jugulars and Liver Congestion
• Diffused thoracic rumors
Echocardiogram: a third hole in the apical septum appears
Evolving infarction of the septal miocardium with increase in
leftright shunt
No more indicaton for a hemodinamic procedure

7. ...and what was effectively done
Implantation of a
peripheric ECMO
(left femoral vein-> left
femoral artery)
as bridge to recovery
or to
transplantation

8. ECMO course
96 hrs on mechanic circulatory support
• Surgical revision for bleeding
• 4 RBC - No other emoderivatives
• After 13 Hours estubated
• Echo was showing no improvement in LV nor RV
function
• On the 5° day: left leg malperfusion->
augmented heparin infusion
• On the 5° day Transplantated with emergency
criteria (Status I)

9. Transplantation course
• Resternotomy assisted by institution of CPB with the
ECMO cannulae than Bicaval-femoral artery
cannulation on total hypotermic CPB
• Emoderivatives consumption: 10 platlet,4 FPC,6 RBC
(of which 2 on CPB)
• After 24 hrs estubated
• Recovery of diuresis after 24 hrs of CVVH and
normalization of renal parameters after 8 days
infusion of Fenoldopam 0.1 γ/kg/min
• Total ICU stay lenght: 10 days
• Discharged on the 28° postoperative day
• Complete recovery of the ischemic neurologic damage
of the left leg with a institutional rheabilitation
program
• Now on NYHA I after 6 months follow-up. No
complications occurred

10. Conclusions
ECMO implantation may be an eccellent way to
stabilize IVS rupture and bridge it to a successfull
surgery whenever surgery is feasible or to Heart
Transplantation if surgery carry a prohibitive risk.
Case in which recovery of a sufficient myocardial
function is unlikely should also be considered for
such a strategy.