JACC: CARDIOVASCULAR INTERVENTIONS

VOL. 8, NO. 2, 2015

ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 1936-8798/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jcin.2014.08.017

IMAGES IN INTERVENTION

When Collateral Damage Does Matter Iatrogenic Ventricular Septal Rupture After Percutaneous Coronary Intervention of the Left Anterior Descending Artery Vincent Michiels, MD,* Martin J. Swaans, MD,* Bastiaan J. Sorgdrager, MD,y Rolf F. Veldkamp, MD, PHD,y Robin H. Heijmen, MD, PHD,z Jurrien M. ten Berg, MD, PHD*

A

n 83-year old woman with no cardiac history

However, 8 days later, she was readmitted because

was admitted because of a non–ST-segment

of acute pulmonary edema. Transthoracic echocardi-

elevation myocardial infarction for which

ography showed a ventricular septal rupture with a

she underwent a diagnostic coronary angiography.

large interventricular septal defect, as confirmed on

The culprit lesion was considered to be a 70% stenosis

cardiac computed tomography (Figures 1C and 1D).

in the mid left anterior descending coronary artery

Initially, she was stabilized and recompensated with

(LAD) just after the origin of a large septal branch

the use of intravenous diuretics and an intra-aortic

(Figure

intervention

balloon pump. The defect was closed surgically with

(PCI) was carried out with implantation of a drug-

a bovine pericardial patch (Figures 1E and 1F). The

eluting stent (3.0  12-mm Promus Element, Boston

patient had an uneventful postoperative recovery.

1A).

Percutaneous

coronary

Scientific, Natick, Massachusetts). After stent implan-

This case shows the post-PCI complication of an

tation, there was an occlusion of the septal branch,

iatrogenic occlusion of a septal branch that caused

presumably caused by plaque shift. Despite several

extensive infarction of the interventricular septum

attempts, the branch could not be rewired, so the oc-

leading to ischemic rupture. It reminds us that

clusion was accepted (Figure 1B). The patient was dis-

leaving a septal branch occluded after PCI of the LAD

charged in good clinical condition 2 days after the

is not without risk, and every attempt should be

procedure (maximum creatine kinase, 1,760 U/l).

made to restore flow.

From the *Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands; yDepartment of Cardiology, Medisch Centrum Haaglanden, Den Haag, the Netherlands; and the zDepartment of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

368

Michiels et al.

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 2, 2015 FEBRUARY 2015:367–8

Iatrogenic VSR After PCI of the LAD

F I G U R E 1 Different Stages and Imaging Modalities of the VSR After PCI

(A) Angiography before PCI. Arrow indicates stenosis. (B) Angiography after PCI. Arrow indicates the occluded septal branch. (C) Transthoracic echocardiogram, 4-chamber view. Arrow indicates the septal defect. (D) Volume-rendered cardiac computed tomography image, 4-chamber view. Arrow indicates the septal defect. (E) Perioperative photograph before closure of the VSR. Arrow indicates the septal defect. (F) Perioperative photograph after closure of the VSR. LV ¼ left ventricle; P ¼ patch; PCI ¼ percutaneous coronary intervention; RA ¼ right atrium; RV ¼ right ventricle; SB ¼ septal branch; VSR ¼ ventricular septal rupture.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

Vincent Michiels, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands. E-mail: [email protected].

KEY WORDS interventional cardiology, ischemic heart disease, non-ST-segment elevation myocardial infarction