This document discusses ventricular septal defects (VSDs) that occur after a myocardial infarction. It provides several key points: 1. Surgical repair is the gold standard treatment for post-infarction VSD, but patients are at high risk for complications and mortality rates remain poor. 2. Transcatheter device closure of VSDs is an emerging alternative to surgery, with studies showing high rates of technical success but also risks of major complications and death within 30 days. 3. Factors associated with increased mortality from both surgical repair and device closure include older age, cardiogenic shock, renal dysfunction, and larger defect size. Overall, post-infarction VSD continues to carry

1. Ventricular septal defect after
myocardial infarction
Wait to heal

2. Condolence
• Patients are usually fragile, and manipulation of the heart, systemic
hypotension, and contrast load contribute to renal dysfunction,
hypothermia, acidosis, and hypoperfusion. Patients who survive the
procedure remain at risk of subsequent demise because of extended
rupture, free wall rupture, renal failure, inflammation, sepsis, vascular
access complications, and multiorgan failure.
• One month survival at the end of one without surgery or intervention
month is only 6%

3. ACC/AHA /ESC guidelines
• Surgery is gold standard
• Ignore shunt size
• Ignore duration
• Close at the earliest

4. When to operate ?
• If possible to delay >2 weeks

5. Potential alternative to surgical repair
• Amplatzer
• Cardi-O-Fix device

6. Balloon sizing
• It is bad

7. World’s largest series of PMIVSD device
closure
• Single-centre
• Retrospective, cohort study
• Transcatheter closure between 1988 and 2008 at Boston children’s hospital
• Direct percutaneous VSR closure or closure of a residual VSR after
• Primary outcome was mortality rate at 30 days
• Statistics: Univariate logistic regression
• Thirty patients
• A total of 40 closure devices were implanted
• Major periprocedural complications occurred in 4 (13%) patients
• Cardiogenic shock, increasing pulmonary/systemic flow ratio, and the use of the new generation
(6-arm) starflex device all were associated with higher risk of mortality
• The model for end-stage liver disease excluding international normalized ratio (MELD-XI) score at
the time of VSR closure seemed to be most strongly associated with death (odds ratio, 1.6;
confidence interval, 1.1–2.2; p<0.001).

8. PMIVSD device closure: In-Hospital Outcomes
and Long-Term Follow-Up of UK Experience
• Attempted in 53 patients from 11 centres (1997–2012; aged 72±11 years; 42% female).
• Nineteen percent had previous surgical closure.
• AWMI - (66%) or inferior (34%)
• Time from MI to closure procedure was 13 (first and third quartiles, 5–54) days
• Successfully implanted in 89%
• Immediate complications included procedural death (3.8%) and emergency cardiac surgery (7.5%)
• Immediate shunt reduction : complete (23%), partial (62%), or none (15%)
• Median length of stay after the procedure was 5.0 (2.0–9.0) days.
• Fifty-eight percent survived to discharge
• Followed up for 395 (63–1522) days, during which time 4 additional patients died (7.5%)
• Factors associated with death
• age (hazard ratio [HR]=1.04; P=0.039), female sex (HR=2.33; P=0.043), New York Heart Association class IV (HR=4.42;
P=0.002), cardiogenic shock (HR=3.75; P=0.003), creatinine (HR=1.007; P=0.003), defect size (HR=1.09; P=0.026), inotropes
(HR=4.18; P=0.005), and absence of revascularization therapy for presenting myocardial infarction (HR=3.28; P=0.009). Prior
surgical closure (HR=0.12; P=0.040) and immediate shunt reduction (HR=0.49; P=0.037)

9. Surgery
• Society of Thoracic Surgeons National Database
• n=2876
• Operative death was 42.9%
• independent predictors of operative mortality
• Age
• Female sex
• Shock
• Preoperative aortic counter pulsation balloon
• Redo surgery
• Emergency status
• Preoperative dialysis
• Mitral insufficiency

10. Thiele H, Kaulfersch C, Daehnert I, Schoenauer M, Eitel I, Borger M, Schuler G.
Immediate primary transcatheter closure of postinfarction ventricular septal defects.
Eur Heart J. 2009;30:81–88
• 29 cases in a single centre over a 6-year period
• Attempted 1 to 3 days after diagnosis
• Eighty-six percent of patients had a technical success of device
implantation
• 17% died in the catheter laboratory
• 41% had major complications
• Survival to 30 days was only 35%
• Many patients still die early because of complications of the disease
process itself

11. Message from PMIVSD
From graveyard