Septal rupture and mitral regurgitation: 13 years of survival with all-percutaneous approach

Post-infarction septal rupture: record survival of a 100% percutaneous approach

Post-infarction ventricular septal defect (PIVSD) remains one of the most formidable complications of the acute phase of infarction, with a heavily compromised vital prognosis. While surgery is the gold standard treatment according to ESC guidelines, it becomes extremely risky when it must simultaneously address complex coronary lesions and severe mitral regurgitation (MR), particularly in cases of initial cardiogenic shock.

This case report details the management of a 65-year-old female patient presenting with an inferior PIVSD, left main coronary artery stenosis, and massive MR, a situation deemed surgically futile by the Heart Team. The objective is to demonstrate the feasibility and durability of an exclusively percutaneous and sequential alternative strategy. Through this case, the authors test the hypothesis that a combination of coronary stenting, septal closure using an Amplatzer device (24 mm), and subsequently, a transcatheter edge-to-edge repair (TEER), can ensure long-term survival. The major scientific interest lies in the exceptional 13-year clinical follow-up, providing rare data on the durability of these combined transcatheter interventions in a multi-pathological patient.

Methodology

This clinical case report describes the sequential therapeutic strategy adopted for a 65-year-old female patient admitted in cardiogenic shock. The initial clinical presentation combined an occlusion of the right coronary artery, severe stenosis of the left main stem, an inferior post-infarction ventricular septal defect (PIVSD), and severe mitral regurgitation (MR).

• Assessment and stabilization: Hemodynamic stabilization was ensured by intra-aortic balloon pump (IABP), in accordance with ESC guidelines. ECG-gated cardiac CT imaging allowed for precise quantification of the septal defect, measuring 19 mm x 10 mm in diastole and 15 mm x 9 mm in systole.
• Interventional protocol (Day 2): The procedure began with stenting of the left main coronary artery. Percutaneous closure of the PIVSD was performed under general anesthesia by creating an arteriovenous wire-loop established between the femoral artery and the right internal jugular vein (retrograde passage of the defect and snare of the guidewire in the pulmonary artery).
• Device and implantation: A 24 mm Amplatzer PIVSD occluder device (maximum available diameter) was deployed via a 10 French sheath introduced through the right internal jugular vein.
• Analysis and monitoring: The positioning of the device was monitored in real time by fluoroscopy and transoesophageal echocardiography (TOE) to validate the reduction of the left-to-right shunt. Detailed clinical follow-up covers the initial critical phase and the 38-day hospitalisation.

Results of percutaneous management

The ECG-gated cardiac CT scan allowed for the characterization of the anatomy of the post-infarction ventricular septal defect (PIVSD). The measurements revealed an oval-shaped defect located in the inferior part of the ventricular septum.

Parameter (CT Scan)	Dimensions in Diastole	Dimensions in Systole
Ventricular Septal Defect (VSD)	19 mm x 10 mm	15 mm x 9 mm

Procedure and immediate technical success

The therapeutic strategy began with stenting of the left main coronary artery two days after admission. Percutaneous closure of the VSDP was performed via a right internal transjugular approach using a 24 mm Amplatzer VSDP device (the largest diameter available).

• Hemodynamics: Significant reduction of the left-to-right shunt immediately after placement.
• Residual flow: Persistence of a low volume of flow through and around the device tissue.
• Stabilization: Removal of the intra-aortic balloon pump (IABP) possible 24 hours after the procedure.

Clinical evolution and complications

The hospital stay was marked, approximately one week after the procedure, by an episode of atrial flutter with 2:1 block, leading to profound hemodynamic decompensation. This complication required a new IABP insertion and electrical cardioversion under brief anesthesia.

Despite persistent symptoms of initial heart failure, the patient's condition gradually stabilized under optimal medical treatment. She was able to return home after a total hospitalization of 38 days.

Long-term follow-up

The patient benefited from a sequential percutaneous strategy over several years to treat recurrent chest pain and severe mitral regurgitation. This approach included several coronary stenting procedures as well as a transcatheter edge-to-edge repair (TEER) using a clip. At nearly 13 years of follow-up, the patient is still alive and maintains a satisfactory quality of life under medical treatment, despite a minimal residual leak at the septal device.

This case study demonstrates the viability and, above all, the long-term durability of an entirely percutaneous strategy for complex post-infarct complications. Clinically, it proves that the sequential approach — treating ischemia, then the septal defect, then the valvular pathology — allows for the stabilization of patients in cardiogenic shock where combined surgery would present an unacceptable mortality risk. The main limitation remains the unique nature of this case (n=1) and the necessity of a favorable anatomy (confirmed here by CT-scan) for the Amplatzer device implantation. Nevertheless, compared to classic literature data highlighting the fragility of inferior VSD repairs, the 13-year success is remarkable. This suggests that transcatheter therapy is no longer just a temporary rescue solution, but a credible and sustainable alternative for high surgical risk patients.

In practical terms, for the practitioner:

• Considering the percutaneous approach as a real alternative: In patients rejected for complex surgery (post-infarctus VSD + severe MR), the transcatheter strategy allows for long-term survival (here >12 years) with a preserved quality of life.
• Prefer the sequential approach: Unlike surgery, the percutaneous approach allows for step-by-step stabilization (revascularization, then VSD closure, then delayed MR correction), reducing the cumulative operative risk in the acute phase.
• Validate anatomy by CT scan: A synchronized cardiac CT scan is essential to confirm the anatomical feasibility of percutaneous VSD closure, particularly for complex inferior locations.

Technical lexicon of the study

PIVSD (Post-Infarction Ventricular Septal Defect): Acquired rupture of the interventricular septum, a serious mechanical complication of myocardial infarction (MI) characterized by a left-to-right shunt and high hospital mortality.

IABP (Intra-Aortic Balloon Pump): Intra-aortic balloon pump; temporary mechanical circulatory support device used to stabilize hemodynamics in cases of post-infarction cardiogenic shock.

Amplatzer PIVSD Device: Percutaneous occlusion system specifically designed and certified (CE marking) for the closure of post-infarction ventricular septal defects.

Arteriovenous guide-wire loop: Interventional technique consisting of establishing a continuous guide rail between the femoral artery and the internal jugular vein by crossing the septal defect, thus facilitating the delivery of the delivery sheath.

Cardiogenic shock: A state of acute circulatory failure of cardiac origin, observed here in the patient following an inferior infarction with occlusion of the right coronary artery.

Mitral Regurgitation (MR): Mitral valve insufficiency, identified in this case as having an ischemic etiology with a degenerative component, complicating the clinical management of the septal rupture.

Transoesophageal echocardiography: Invasive ultrasound imaging examination used to confirm the severity of mitral regurgitation and accurately guide the positioning of the septal occluder during the procedure.

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