Postinfarction Ventricular Septal Defect Despite Preserved Left Ventricular Function: Management Challenges and...

Post-myocardial infarction ventricular septal defect (PMIVSD) remains a lethal complication despite modern reperfusion. In patients with preserved or mildly reduced ejection fraction, higher shear across residual jets may increase the risk of device instability and hemolysis after transcatheter closure.

A 48-year-old man presented with PMIVSD 15 days after chest pain. Echocardiography showed a left ventricular ejection fraction of 50% and a 13-mm apicoseptal defect. Surgery was advised but was declined. Percutaneous closure with an 18-mm muscular ventricular septal defect occluder via an arteriovenous loop was performed; however the device embolized to the right ventricular apex hours later. It was retrieved using a snared guidewire loop, and a 28-mm septal occluder was implanted. Severe intravascular hemolysis due to residual shunt developed, and despite intensive supportive therapy the patient died from septic shock.

Surgery remains the preferred treatment for PMIVSD. In patients with preserved or mildly reduced ejection fraction, hyperdynamic ventricular mechanics and high left ventricular-right ventricular gradients increase risks of device embolization, residual shunt, and hemolysis after transcatheter closure.

Surgical repair for PMIVSD should be prioritized when feasible; if transcatheter closure is pursued, stabilization, delayed timing, and careful device sizing are essential.