Endovascular treatment of a traumatic ventricular septal rupture and coronary to ventricular fistula

About 10% of patients with chest trauma present with cardiac injuries, associated with 60% to 97% mortality [1, 2]. Penetrating cardiac traumas may injure not only the myocardium, but also other cardiac structures. Therefore timely and rapid diagnosis is critical for improving patient outcome. A 27-year-old man was admitted to our department with exertional angina and dyspnea limiting his activities in the last week. A grade 2/6 continuous murmur was heard at the left sternal border of his chest. He had a history of sudden cardiac arrest due to stabbing to the thoracic region 1 month ago. According to the patient’s report, he had been taken to the surgery emergently without further evaluation after successful cardiopulmonary resuscitation because of massive pericardial effusion and right ventricular collapse in transthoracic echocardiography (TTE). As operative treatment, a large hemothorax and a tense hemopericardium had been drained, and the right ventricular laceration had been repaired. After a postoperative recovery period with normal control TTE, the patient was discharged. In our clinic, diagnostic transesophageal echocardiography (TEE) revealed turbulent flow with 0.53 mm diameter across the interventricular septum with normal left ventricular dimensions (Figure 1). Diagnostic angiography was performed to detect additional cardiac injuries. On his angiogram, the right coronary artery and the circumflex artery were normal. However, contrast material passed from the left anterior descending artery (LAD) to the right ventricle via a large fistula, the proximal segment of the LAD was large and tortuous, and the distal segment of the LAD after the fistula was very small due to poor distal flow (Figure 2 A). Ventriculography revealed normal left ventricular contraction with contrast flow from the left to the right ventricle at the mid portion of the interventricular septum (Figure 2 B). After discussion with cardiac surgeons we decided that the best therapeutic approach was surgery, but the patient refused the recommended redo surgery. So we decided to continue treatment with percutaneous closure. Before the procedure the patient received 80 mg of gentamicin and 2 g of cefazolin for endocarditis prophylaxis as well as 80 U/kg of unfractionated heparin by the intravenous route. The Seldinger technique was used to insert an 8 Fr introducer into both the femoral artery and jugular vein under general anesthesia. A 7 Fr pigtail catheter was advanced into...


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