World Journal of Cardiovascular Surgery, 2013, 3, 186-189 http://dx.doi.org/10.4236/wjcs.2013.36037 Published Online October 2013 (http://www.scirp.org/journal/wjcs) Copyright © 2013 SciRes. WJCS Multi-Modality Imaging in a Hybrid Setting Facilitates Transcatheter Closure of a Traumatic Ventricular Septal Defect Tamim Nazif, Rebecca T. Hahn, Robert Sommer, Susheel K. Kodali, Mathew R. Williams, Isaac George Divisions of Interventional Cardiology and Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, USA Email: ig2006@columbia.edu Received August 4, 2013; revised September 4, 2013; accepted September 11, 2013 Copyright © 2013 Tamim Nazif et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT We present a case of transcatheter closure of a traumatic ventricular septal defect (VSD), in which simultaneous 3-di- mensional (3D) transesophageal echocardiography (TEE) and angiography played a critical role in defect sizing, device selection, and procedural guidance. Keywords: Ventricular Septal Defect; Transcatheter; Percutaneous 1. Case Presentation A 17-year-old man with no significant medical history suffered multiple stab wounds to the abdomen and chest. Exploratory laparotomy revealed 600 milliliters of blood in the abdomen, but no obvious source of hemorrhage. Immediately afterward, he developed pulseless electrical activity that was felt to be due to cardiac tamponade. An emergent left thoracotomy was performed with decom- pression of the pericardium and repair of a right ven- tricular (RV) laceration. Transfusion was required with more than 10 units of packed red blood cells and other blood products. Post-operatively, physical examination was notable for a loud holosystolic murmur at the lower sternal border. Echocardiography revealed a traumatic VSD with left to right shunting, depressed RV function, and borderline left ventricular (LV) function. The patient was transferred to our institution for VSD repair. On initial evaluation, the patient was deemed to be a poor candidate for cardiopulmonary bypass and surgical VSD repair due to ongoing sanguinous drainage from the abdomen. We therefore elected to proceed with tran- scatheter closure of the VSD in the hybrid operating room, with planned open conversion if unable to com- plete percutaneously. Internal jugular venous and femoral arterial access were obtained. Invasive hemodynamic assessment revealed a significant left to right shunt (Qp/ Qs 1.8), but no pulmonary hypertension. Left ventriculo- graphy confirmed the presence of a VSD with left to right shunting, but was inadequate to allow precise lo- calization or sizing of the defect (Figure 1A). TEE clear- ly demonstrated the defect with left to right shunting, a peak velocity of 3.8 m/s, and Qp/Qs 1.7. Simultaneous multiplane imaging (Figure 1B) and real time 3D imag- ing (Figure 1C) allowed visualization of a funnelshaped, slit-like defect in the mid interventricular septum that was broadest on the RV aspect, measuring 1.1 cm × 1.4 cm and narrowing to 1.0 cm × 0.4 cm on the LV side. The defect tunneled obliquely through the septum with a length of 1.1 cm and narrowest color Doppler jet of 1.0 cm × 0.36 cm. Based on the TEE imaging, we chose to use a 16 mm Amplatzer Post-Infarct (PI) Muscular VSD Occluder (St. Jude Medical, Minneapolis, MN) on a com- passionate use basis. Transcatheter closure of the VSD was performed un- der fluoroscopic and 3D-TEE guidance. The VSD was successfully crossed by a retrograde transarterial ap- proach with a Terumo angled glidewire (Terumo Medical, Somerset, NJ) and a Judkins right coronary catheter. Si- multaneous angiography and multiplane and 3D TEE imaging was performed to guide wire positioning (Fig- ure 2). The wire was then advanced to the left pulmonary artery, snared, and exteriorized via the internal jugular venous access to form a continuous arteriovenous loop. The Amplatzer septal occluder was delivered by the ante-