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case_images: Echo at presentation (a, b: modified long axis, c, d: short axis). [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: The left ventricular ejection fraction (LVEF) was 60% (Figure 1).
case_images: Coronary angiogram:Triple vessel disease. [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: She was taken up for an emergency angiogram, which revealed a triple vessel disease (Figure 2).
case_images: Post surgery echo showing patch dehiscence. [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: IABP was removed on second day post-surgery and subsequently the same evening the patient had a hemodynamic deterioration, which on evaluation revealed a recurrent VSR (Figure 3) due to patch dehiscence.
case_images: Cardiac CT depicting VSR. CT: Saggital (a, b) and axial section (c) of the heart depicting VSR with contrast flow from the left to the right ventricle. (d) 3d reconstruction depicting VSR. [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: A Cardiac CT performed after stabilization confirmed our findings (Figure 4).
case_images: TEE during transcatheter closure (modified 00 view in 2D, 2D-color, 3D, and 3d-color). TEE in modified 0 degree view (a) 2d echo depicting dehisced patch and communication between LV and RV. (b) Colour doppler interrogation revealing left to right shunt. (c) 3d reconstruction depicting pseudoaneurysm and (d) 3d reconstruction with colour doppler interrogation revealing pseudoaneurysm and left to right shunt. [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: On the 12th day post-surgery the patient underwent VSR device closure under transesophageal echocardiogram (TEE) guidance (Figure 5).
case_images: Transcatheter VSR closure:Procedural angiographic stills. (a) LV angiogram revealing VSR, (b) crossing VSR with sion blue wire through a navicross catheter in Judkins right catheter, (c) snaring in the main pulmonary artery, (d) balloon sizing, (e) delivery sheath introduction, (f) LV disc deployment, (g) RV disc deployment, (h) device release, (i) final LV angiogram depicting minimal residual leak, and (j) stable and well positioned device. [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: Videos: S1, S2, S3): Pigtail LV angiogram in LAO view revealed the site of VSR (basal) (Figure 6a). VSR was crossed from the LV side using a Sion blue guide wire (Asahai Intecc Medical) through a Navi-Cross (Terumo Interventional systems) catheter in a Judkins Right (JR) catheter (mother and child technique) (Figure 6b). Navi-cross was parked in the main pulmonary artery (PA). Sion blue was exchanged with an emerald wire (Cordis) while holding the Navi-cross with the snare (Figure 6c). A pigtail LV angiogram during the occlusion showed significant reduction in shunt (Figure 6d). A 12Fr delivery sheath was inserted through the femoral vein over the looped emerald wire and was parked in the LV (Figure 6e). A 18 mm device was introduced with a delivery cable through the delivery sheath keeping the emerald wire intact. The LV disc was deployed followed by an angiogram which showed adequate sealing (Figure 6f). The right ventricular (RV) disc was deployed followed by a device stability check with a pull and tug (Figure 6g). After confirming the stability and position of the device the emerald wire was pulled back from the LV side and the device was released (Figure 6h). Final LV angiogram showed minimal residual shunt (Figure 6i).
case_images: TEE post-procedure showing stable device in situ. [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: TEE confirmed the same (Figure 7).
case_images: Pre-discharge echo: (a) 2D-stable device, (b) 2D color-minimal residual shunt, (c) Qp/Qs 1.4:1. Cx, circumflex artery; LA, left atrium; LAD, left anterior descending artery; LV, left ventricle; PA, pulmonary artery; PMI VSD device, post myocardial infarct ventricular septal defect closure device; RA, right atrium; RCA, right coronary artery; RV, right ventricle; VSR, ventricular septal rupture. [Color figure can be viewed at wileyonlinelibrary.com]
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case_images: Pre-discharge echo revealed a stable device with minimal residual shunt and a Qp/Qs of 1.4:(Figure 8) with an LVEF of 48%.