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.
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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