2019 Scientific Sessions

Title Percutaneous Closure of a Traumatic Ventricular Septal Defect Caused by Stabbing (“The Chicago VSD”) Introduction Penetrating chest trauma is complicated in up to 10% of the cases by a Ventricular Septal Defect (VSD), however the VSD is often not diagnosed at the time of initial event. Clinical Case A 65-year-old male with a history of a penetrating knife wound to the chest with right ventricular free wall injury that was surgically repaired 7 years ago, chronic obstructive pulmonary disease, chronic kidney disease, and cirrhosis, presented to the hospital with several years of intermittent exertional substernal chest pain and 2 months of progressive shortness of breath and fatigue. A transthoracic echocardiogram showed a LV ejection fraction of 30-35%, moderately enlarged ventricular chambers, a restrictive VSD in the peri-membranous of the basal muscular septum with left-to-right color flow Doppler (Vmax=5.8m/s), and estimated pulmonary artery systolic pressure of 65 mmHg. Cardiac MRI showed a small muscular VSD of 6mm by 12mm seen in the basilar septum, just 9mm inferior to the right aortic sinus along the anteroseptal wall with a Qp:Qs of 1.9. Right heart catheterization showed a Qp/Qs of 1.8 with left-to-right shunting, severe pulmonary hypertension, and poor biventricular function. After discussing with the patient, the decision was made to proceed with a percutaneous approach for the VSD closure. Under ultrasound guidance, an 8 French sheath and a 6 French sheath were placed in the right femoral vein and the right femoral artery, respectively. Through the arterial sheath, a pigtail catheter over a J-wire and was used to cross the aortic valve. LV pressure and ventriculogram were obtained. A Judkins Right4 (JR4) diagnostic catheter was exchanged and an angled glide wire was used to cross the VSD. Through the venous sheath, a pigtail catheter was inserted into the pulmonary artery and exchanged over a J wire for a gooseneck snare sheath to snare and externalize the wire. The JR4 catheter was removed and the venous sheath was exchanged for an 8F Amplatzer TorqVue 180 degree sheath. An 8mm Amplatzer muscular VSD occluder was passed through the venous sheath, crossed through the VSD, and the LV disk was deployed. The VSD occluder device was pulled back and the RV disk was deployed. Transesophageal echocardiography confirmed appropriate placement across the VSD. A tug test demonstrated the device was secure. The device was then released and reimaged showing no shunt or effusion. All catheters were then removed, and hemostasis was achieved using percutaneous closure devices. Patient tolerated the procedure without complications and was discharged home with goal directed heart failure medications, life-long aspirin, and three months of clopidogrel. Discussion Management of post-traumatic residual VSDs is not clearly defined. At minimum, VSD repair should be considered in the presence of significant left-to-right shunting and poor ventricular function. Percutaneous closure of VSDs can be a safe alternative to surgical techniques.