three vsd closuresjcr.kr/upload/post_case/1577164096_phppzawax_315.pdf · 2019. 12. 24. · vsd due...
TRANSCRIPT
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Three VSD Closures
Jae-Hwan Lee, MD, PhD
Cardiovascular Center in
Chungnam National University Hospital
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Case 1. VSD due to Stab Injury
13 YO boy
Multiple stab injury by his psychotic brother
Massive bleeding from the chest stab wound,
- 3 cm laceration
- Deepest wound with bleeding in superolateralportion of the left nipple
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Rt neck
ForeheadFacial
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Rt. ankle Back
Lt. chestBack
deepest wound
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He arrived at other general hospital with a shock state,
sBP; 60 mmHg
Active bleeding from
the chest stab wound
Initial Hb 6.0g/dl
After chest tube insertion,
→ Initial 800 cc bleeding
→ Continued bleeding
→ Chest tube was clamped
→ Transfer to our ER
→ Immediately moved to OR
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1st Operation
LV laceration
2cm
Cardiac arrest at OR
→ External cardiac massage
→ Median sternotomy
→ Open cardiac massage
→ Relief cardiac tamponade
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LV repair
LV laceration site closure
with interrupted plageted
5-0 prolene suture
Lacerated pericardium
Simple closure of LV laceration
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Intrathoracic bleeding control
4 th rib Fx at sternocostal jointIntercostal v. bleeding
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Intraoperative TEE after
ventricular wall repair
Large muscular VSD near the apex (with L-R shunt)
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2nd Operation
Repair of traumatic VSD with Dacron patch
Traumatic VSD
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Septal Defect Repair
Repaired
LV laceration
LV-tomy for VSD
repair, 3.5cmLV-tomy & VSD repair
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Intraoperative TEE after VSD repair
Still residual defect but, could not assumed the amount of cerebral injury
→ Surgery was completed with residual defect
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Postop. TTE (2 weeks later)
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6 months later (DOE Fc 2)
Qp/Qs = 2.2, peak PA pr 54 mmHg
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LVRV
Patch
General anesthesia, TEE guidance
L→R passage and Snared from femoral vein
6 mm defect diameter
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7 Fr delivery sheath, 10 mm muscular VSD device
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LVRV
PatchAmplatzer device
Too deep → protruded to the LV
Device Positioning
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LV
RV
PatchAmplatzer
Device
Too superficial →
LV disc expanded in the VSD tunnel
Device Positioning
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Final Device Position
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Qp/Qs <1.2, minimal residual shunt on TEE
Device Detached
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16 years later (Now 29 YO man)
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The 2nd case, Infarct VSD
• F/76, 20 PY smoker, Previous healthy
• 5 DA, continuous resting pain for 12 hrs
followed by worsening dyspnea
• P/E
V/S 94/62 mmHg – 110 – 26 – 36.5C
Pansystolic murmurs on LLSB, IV/VI
Coarse inspiratory crackles on BLLF
• Enzyme
CK / MB / Tn-I 99 / 1.72 / 2.60
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Initial CXR
Delayed presentation of anterior STEMI with pulmonary edema
Initial ECG
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TTE
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TTE; VSD measurement
7 mm defect on apical septum
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HF management for 2 days → Angiogram
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2.5 mm balloon
Thrombosuction
POBA and Thrombosuction
TIMI 0 flow
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Improved pulmonary edema,
but DOE while moving to the bath room
Surgery recommended → reluctant
→ percutaneous VSD closure planned
1 week later FU Angiogram
Somewhat improved but,
poor distal to-and-fro runoff
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LV Angiogram
Qp/Qs=2.5, peak PA pressure 50 mmHg
ASD occluder
; not permitted
m-VSD occluder
; Not available
Amplatzer Occluder
Off label use of ASD occluder
; thin VSD defect
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JR 5Fr + Terumo .035’’ → Snared from the femoral vein
General anesthesia, TEE guidance
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9 Fr sheath delivery
TEE Measurement
9 mm defect
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Positioning & Detachment
Amplatzer ASD 18 mm occluder
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Wiggling & Detachment
Amplatzer ASD 18 mm occluder
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Residual Shunt
Qp/Qs 2.5 → 1.7
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At 10 days
Still DOE Fc IIb - III
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1 month laterLV EF 40-45%
Still remnant shunt, TR Vmax 3.2m/sec
But, persistent DOE Fc III
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Coil Embolization
Three colis (11, 9, & 7 mm)
Qp/Qs 2.2 → 2.0Radial a + Femoral v
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13 years later
(Now 89 YO woman)1 Month later
Broken coil tip in TV
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The 3rd case, Infarct VSD
• M/67, Anterior STEMI → Visited 2 days later
• HF with pulmonary edema
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EF 35%, Infarct VSD
Pulmonary edema
mLAD occlusion
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VSD patch closure with ECMO
At 2 weeks,
Pulmonary edema
Hepatic congestion
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VSD closure with Amplatzer m-VSD 16 mm occluder
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VSD closure with Amplatzer m-VSD 16 mm occluder
Small remnant, but happy for 4 yrs
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Percutaneous Closure For Infarct VSD
• Optimize hemodynamics with appropriate support
• Surgical vs. Percutaneous closure → should be individualized
• Timing for closure → should be individualized
• Sizing for device selection → not established yet
• Beware of complications
- Device embolization, Remnant shunt, LV rupture, Arrhythmia…
• Can be a good alternative option to surgery