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[Cardiogenic shock complicating extensive infarction with ventricular septal defect. Circulatory assistance and heart
1Service de chirurgie cardiovasculaire (Pr M. David), hôpital du Bocage, CHU Dijon, BP 1542, bd de Lattre-de-Tassigny, 21034 Dijon.
Insights
This case highlights a patient with myocardial infarction and cardiogenic shock who developed a ventricular septal defect. Mechanical circulatory support was initiated, followed by successful cardiac transplantation.
Area of Science:
- Cardiology
- Cardiovascular Surgery
Background:
- Massive anterior myocardial infarction leading to cardiogenic shock.
- Development of a ventricular septal defect (VSD) with significant left-to-right shunt.
- Initial management included angioplasty, intra-aortic balloon pumping, and inotropic support.
Observation:
- Biventricular assist device (MEDOS) implantation was performed due to persistent hemodynamic instability.
- Transesophageal echocardiography revealed progressive VSD shunt increase, device flow decrease, and thrombus formation.
- Complications included cardiac tamponade, necessitating drainage, and valve blockage requiring anticoagulation adjustment.
Findings:
- The patient's condition stabilized after managing complications and before cardiac transplantation.
- Successful orthotopic heart transplantation was performed on the 8th day.
- The case underscores the complexities of managing VSD post-myocardial infarction with mechanical circulatory support.
Implications:
- Challenges in the daily monitoring and management of cardiac assist devices.
- Cardiac transplantation as a viable option for patients with VSD and cardiogenic shock refractory to mechanical support.
- Importance of vigilant surveillance for device-related complications and timely intervention.
Abstract:
A 47 year old man had a massive anterior myocardial infarction with cardiogenic shock with a left parasternal murmur. Coronary angiography showed occlusion of the left anterior descending artery for which angioplasty resulted in failure. There was antero-lateral-apical akinesia and a ventricular septal defect (VSD) with a left-right shunt (Qp/Qs = 1.54). Persistence and aggravation of haemodynamic instability led to intra-aortic balloon pumping with inotropic pharmacological support followed by biventricular assistance with a MEDOS device. Under transoesophageal echocardiographic monitoring, the outcome was marked over 7 days by the progressive increase in the shunt volume of the VSD, a decrease of drainage and injection flow, progressive increase in spontaneous contrast echos followed by the presence of fibrin in the cardiac chambers and canulae, the presence of thrombus in the external ventricles, blockage of the right external valve which only opened after increasing the degree of anticoagulation, and, finally, cardiac tamponade which required drainage before the patient's state improved. On the 8th day, the patient being stable with a normal neurological status, the availability of a donor heart led to the decision to transplant, which was carried out without complications. This case poses the problem of cardiac assist devices and their daily monitoring, and then that of cardiac transplantation in this indication.