Percutaneous Repair of Ventricular Ruptures
Cardiac rupture is a potentially life-threatening complication of myocardial infarction. Ventricular septal defects (VSDs) are the most common form, occurring in <0.5% of myocardial infarctions, and they are associated with a high mortality rate. Free wall ruptures can also occur, leading to cardiac tamponade or pseudoaneurysm formation. Iatrogenic pseudoaneurysms are also described following left ventricular (LV) cannulation. The timing and modality of repair of these defects remain controversial, and the small body of available observational data is heavily confounded. Issues to be considered include the patient’s comorbidities and hemodynamics, infarct and rupture location, and the lesion anatomy.

Although it has been suggested that a lower operative mortality may be incurred by operating after the immediate post-infarct period, this may reflect selection bias, and in the acutely unstable patient, deterioration secondary to cardiogenic shock is inevitable without intervention or hemodynamic support. Pharmacological support with vasoactive agents to maintain end-organ perfusion comes at the expense of increased myocardial workload. Mechanical support with devices such as the intra-aortic balloon pump (IABP) and the Impella pump (Abiomed, Danvers, Massachusetts) reduce myocardial workload, whereas venoarterial extracorporeal membrane oxygenation offers excellent end-organ perfusion at the expense of increased afterload.

However, all these devices require moderate- or large-bore arterial cannulation while the device is in situ, with the attendant risk of complications. Percutaneous transcatheter techniques are much less invasive than surgery and offer the potential for definitive repair, although there are no data comparing these approaches. If a percutaneous technique is to be considered as an option, it is essential to delineate the anatomy of the lesion, in particular the defect size (in 3 planes), surrounding tissue rims, and location in relation to potential routes of percutaneous access that may influence the ease of device delivery. Pre-procedural multimodality imaging can be invaluable in this regard. Access to, and familiarity with, a variety of devices is also required. This report presents 3 cases of percutaneous repair achieved by different methods.