Department of Cardiolog Shenyang Northern Hospital Transcatheter closure of ventricular septal defect in combination Transcatheter closure of ventricular septal defect in combination with PCI in patients with ventricular septal defect complicating AMI: A multicenter study Yaling Han M.D. Department of Cardiolog Shenyang Northern Hospital

Background VSD following AMI is a fatal complication which occurs in 1 to 3 percent of patients with AMI in the era before reperfusion therapy Postinfarction VSD still carry a poor prognosis Mortality is approximately 50% with surgery performed within 3 weeks. VSD closure has become a treatment option for patients with postinfarction VSD

Purposes To assess the immediate and long-term effects of transcatheter closure of ventricular septal defect (VSD) in combination with percutaneous coronary intervention (PCI) in patients with VSD complicating acute myocardial infarction (AMI)

Paticipant centers Ya-ling Han, Xian-yang Zhu, Shenyang Northern Hospital Yong-wen Qin, Changhai Hospital, Shanghai Ping Wang, Qingdao Center Hospital Ying-fen Liu, Zhujiang Hospital Ya-wei Xu, Tongji Hospital

Methods Study patients Between April 2001 and December 2009, 18 AMI patients complicated with postinfarction VSD underwent attempted transcatheter VSD closure and PCI therapy in 5 Chinese Centers. Entry criteria included the presence of a VSD as a result of preceding MI, diagnosed by echocardiogram

Methods Exclusion criteria Patients with a VSD sizing on echocardiography in excess of the maximum available size of the Amplatzer postinfarction muscular VSD device, total occlusion of the target vessel unable to be passed though by guide wire and left ventricular aneurysm were

Methods Devices Amplatzer postinfarct muscular VSD (PIMVSD) occluder (AGA Medical Corporation. USA) or a modified double-disk occluders (Shanghai Shape Memory Alloy Ltd, China) The coronary stents included Sycro , Zeta , BX , Tsunami, Accura, Firebi, Endeavor and Diamond-Flex,Taxus Liberte

Methods Follow up Before discharge, patients underwent transthoracic echocardiography to further confirm correct device position. All patients were followed up clinically and by X-ray, electrocardiography and echocardiography at 1, 3, 6 and 12 months after transcatheter closure and thereafter at 6-month intervals.

Results Clinical Baseline(1) * Variable Results Age (years) 67.2 ± 6.4 Female gender 9 /18(50.0 %) Diabetes mellitus 7/18 (38.9 %) Hypertension 8/18 (44.4%) History of stroke 2/18 (11.1%) *

Clinical Baseline(2) * Variable Results Region of MI   Extensive anterior wall MI 14/18 (77.7 %) Anteroseptal wall MI 2/18 (11.1 %) Anterior and inferior wall MI 1/18 (5.6 %) Inferior AMI with old anterior MI 1 /18 (5.6 %) Cardiogenic shock 7 /18 (38.9 %) Biventricular failure Size of VSD by echocardiography (mm) 10.5 ± 4.9 *

In-hospital outcomes Sixteen of 18 patients underwent both successful transcatheter VSD closure and PCI therapy 15 of them survived till discharge The total procedural success rate was 88.9 % (16/18) and the in-hospital survival rate was 83.3 %（15/18） Three (16.7 %) patients died in hospital. The LVEF increased from 0.38 ± 0.09 (n=15) at admission to 0.49 ± 0.08 at discharge (P<0.05)

Outcome of percutaneous device closure (1) Variable Results Urgent transcatheter VSD closure 6/18 (33.3%) Elective transcatheter VSD closure 12/18 (66.7%) One defect 16/18 (88.9%) Two defects 2/18 (11.1%) Device success 90.0 % (18/20) Procedure success 88.9 % (16/18)

Outcome of percutaneous device closure (2) Variable Results Shape of defects closed by devices   Tubulous 16/18 (88.9%) Funnel-shaped 2 /18 (11.1%) Residual shunt: immediate result 7/18 (38.9%) Small Moderate 5 /18 (27.8%) Residual shunt: at discharge 5/15 (33.3%) Residual shunt: at last follow up 3/15 (20.0%) Death 3/18 (16.7%) Procedure-related 1/18（5.6%） Unrelated 2/18 (11.1%)

Outcome of PCI The mean duration from AMI symptom onset to PCI was 39.4 ± 28.6 days 27 stents , 1.5 stents per patient, 3.5 ± 0.4 mm in diameter and 24.8 ± 14.6 mm in length The immediate PCI success was 100% without major procedural complications

Follow up Mean follow up time from discharge was 43 ± 22 months (ranging from 5 to 80 months) LVEDD from 64.5 ± 4.6 mm to 54.4 ± 3.2 mm (P<0.05) At the most recent outpatient follow-up, there was no late death or recurrent shunt

Conclusions Transcatheter VSD closure with concomitant PCI therapy provides a therapeutic option for patients with VSD complicating AMI with satisfying long term efficacy. This procedure can be performed successfully in patients with anatomically suitable VSDs and coronary vessels

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