Delayed Device Closure of Apical Ventricular Septal Rupture Following Iatrogenic LAD Occlusion: A Case Report

Abstract

Background: Ventricular septal rupture (VSR) is an uncommon but potentially fatal mechanical complication of acute myocardial injury. Although surgical repair remains the conventional treatment, transcatheter closure is increasingly used in selected high-risk patients for whom delaying intervention may permit stabilisation and organisation of infarcted septal tissue, potentially improving device anchoring and procedural success. Case Summary: A 56-year-old woman with diabetes mellitus, hypertension, and tobacco use presented with unstable angina and a preserved LVEF of 60%. Coronary angiography demonstrated double-vessel disease, and LAD PCI was performed. The procedure was complicated by acute LAD dissection with abrupt vessel closure. Attempts at rewiring and balloon dilatation failed to restore adequate perfusion, with final TIMI grade 1 flow. The patient developed hypotension requiring inotropic support, and LVEF decreased to 45–50%. Within 2 days, an apical VSR measuring approximately 12 mm developed. Following multidisciplinary heart-team discussion, immediate closure was deferred because the patient stabilised without progressive haemodynamic deterioration, with serial inflammatory and myocardial injury markers progressively resolving. After more than 25 days, LVEF recovered to approximately 60%. The VSR was subsequently closed successfully using an 18-mm Lifetech muscular VSD occluder. Conclusion: The case illustrates an unusual iatrogenic mechanism of VSR and highlights the potential value of controlled, biomarker-guided intervention in clinically stable patients. In appropriately selected patients, waiting may become part of the strategy, thereby facilitating successful transcatheter closure.