post - infarction ventricular septum rupture ( vsr ) is a rare mechanical complication of an acute myocardial infarction ( ami ) . due to the use of aggressive antithrombotic medication and more efficient revascularisation therapy , the incidence of post - infarction vsr has decreased from 12  % to 0.250.31  % . an acute left - to - right shunt following a vsr may lead to acute haemodynamic deterioration . when conservative treatment is applied , mortality rates are as high as 87100  % [ 2 , 3 ] . unfortunately , even surgical patch repair has a high mortality of 47  % in the first 30  days after closure . to date , the american college of cardiology and american heart association ( acc / aha ) still advise immediate surgical closure of the vsr , often combined with ( multiple ) coronary artery bypass grafting . due to the high mortality rate , less invasive alternative treatments , such as the use of percutaneous occluders , have been investigated . this article gives an overview of recently published experiences with the use of percutaneous occluders as a treatment for vsr . for this systematic review we used the search engine pubmed to browse through the online database medline using the following mesh terms : [ ventricular septal rupture ] or [ ventricular septal defect ] and [ myocardial infarction ] and [ septal occluder device ] or [ transcatheter ] or [ percutaneous ] . were included as we believed they were less sensitive to a selection bias than pure case reports . the technique of percutaneous closure of a vsr is based upon the well proven and widely used percutaneous technique for closing a congenital ventricular septal defect . echocardiography with colour doppler is used to determine the size and anatomy of the vsr . more detailed information about the lesion could be obtained by other imaging methods , such as computed tomography , but up till now only few case reports have been published . indication for a surgical or a percutaneous closing technique should be on a case - by - case basis . cannulation of the femoral artery and femoral vein or internal jugular vein is performed using the seldinger technique . a guidewire is introduced into the artery , through the aortic valve and is advanced through the vsr into the right ventricle and pulmonary artery . a second snaring wire is introduced through the vein to connect to the guidewire in the pulmonary artery . by retracting the snared wires an alternative method is by creating a venovenous ( vv ) loop . in this method the initial guidewire , inserted via de femoral vein , perforates through the atrial septum into the left heart system . it then travels via the vsr into the right ventricle and will be snared in the pulmonary artery . the procedure is at that point the same as with the av - loop method . the delivery sheath is advanced from the venous side loop over the guidewire through the vsr into the left ventricle . using fluoroscopy and/or echocardiography , correct positioning of the delivery sheath once echocardiographic confirmation of the necessary device size has been achieved , the device is placed inside its catheter and advanced through the vsr using the delivery sheath . the distal disc is opened , the device is retracted , so that it will be secured against the septal tissue at the side of the left ventricle . correct positioning of the device and closure is confirmed by echocardiography and/or fluoroscopy . if placement is satisfactory , the occluder is released . an anterior or inferior ami may lead to vsr formation due to progressive septal tissue necrosis . the vsr diameter will often increase over time until stabilisation , due to the scarring of the surrounding tissue . localisation is also an important factor as an apical or perivalvular vsr might not be suitable for percutaneous occlusion . when treating a perivalvular vsr the device may interfere with valvular components [ 6 , 7 ] . due to the presence of the ventricle free walls , an apically located vsr might pose difficulties in correctly positioning the device , thus making these vsr localisations more challenging . a congenital vsd is often symmetrical , has strong borders and a relatively straight connection between the left and right ventricle . in contrast , a vsr forms due to acute ischaemic damage of the septum . as a result , a vsr is an asymmetrical tear with unstable necrotic borders . in post - mortem research vsr simple vsrs are straight horizontal septal canals whilst complex vsrs travel serpiginously through the septum before exiting at a different level . 1simple ( a ) versus complex ( b ) ventricular septal rupture simple ( a ) versus complex ( b ) ventricular septal rupture percutaneous closure of a complex vsr is obviously more challenging , but once a correct av loop or vv loop is achieved , device placement is possible . based on the existing literature , a variety of devices for percutaneous closure of a vsr have been used . these devices are the atrial - septal - defect occluder ( asdo ) , muscular - ventricular - septal - occluder ( mvsdo ) and recently a specific post - infarction mvsdo occluder ( pimvsdo ) developed by amplatzer . the diameters of the applied devices were , on purpose , significantly larger than the diameter of the vsr measured using different imaging techniques . some authors even stated that the optimal diameter should be twice the size of the measured vsr diameter or at least 10  mm larger [ 10 , 11 ] . this prevents incomplete closure or dislodging and embolisation of the device due to continued septal necrosis . occlusion in the chronic phase demanded occluding devices that were only moderately larger in diameter than the measured vsr . it is not yet certain which occluder device is the best option for the treatment of a vsr . however , only the use of asdo was not the best treatment option , especially in the acute phase . due to the fact that the combination of a high pressure gradient between the two ventricles and the high permeability of an asdo , it was unable to provide sufficient occlusion of the vsr . this device has a wider waist , larger disks and a denser construction , which should lead to a faster occlusion over a wider septal region . apart from the technical aspects , the personal preference of the treating physician will also affect the decision as to which occluder device will be used during the procedure . as mentioned earlier , the acute necrotic septum forms an inadequate base for surgical patch repair . therefore , despite acc / aha guidelines , there is a tendency to defer surgical treatment by 24  weeks . in this time the necrotic process will stabilise and scarring of the surrounding tissue will occur , which will form a better fundament for a successful fixation of the patch . the decision as to whether deferring is feasible or not should be based on the haemodynamic stability of the patient . patients will typically be treated with supportive medication , an intra - aortic balloon pump ( iabp ) and/or mechanical circulatory support ( msc ) [ 11 , 15 ] . acute - phase occlusion was defined as closure within < 14  days after diagnosis of the vsr . in the acute phase , patients are often critically ill and have high logistic euroscores . despite high procedural success ( 5086.2  % ) , haemodynamic stabilisation is often not achieved , leading to a very high residual mortality of 42100  % [ 11 , 1619 ] . treatment during the chronic phase was defined as 14  days after diagnosis of the vsr . occlusion was performed on haemodynamically more stable patients , weeks or even months after vsr formation . procedural success is high ( 71.4100  % ) and coincides with a lower mortality rate of 2038.9  % [ 12 , 2022 ] . table  1 summarises the included case series.table 1procedure characteristicsauthor , publicationyearvsr patientsacute phase ( < 14  d)chronic phase (  14  d)time between vsr diagnosis and occlusionsuccesful device placementmortalityassenza et al . ( 2013 ) 30med : 27  d7/30maltais et al.(2009 ) 12120mean : 6,1  d5/12thiele et al . ( 2009 ) 29290mean : cs : 1  d25/29cs : 13/14mean : non - cs : 3  dnon - cs : 4/11ahmed et al . ( 2002 ) 123910/12total176627891/110 ( 82.7  % ) 61/162 ( 37,7  % ) 
 ami acute myocardial infarction , vsr ventricular septum rupture , med median , cs cardiogenic shock procedure characteristics 
 ami acute myocardial infarction , vsr ventricular septum rupture , med median , cs cardiogenic shock patients suffering from a vsr will frequently present with cardiogenic shock ( cs ) due to an acute left - to - right shunt complicating the initial ami . the presence of cs is associated with a tremendous increase in mortality . in the prospective research of thiele et al . the acute - phase mortality , in this specific research defined as closure within 30  days after vsr diagnosis , in the cs population was 86  % ( n  =  12/14 ) increasing to 93  % ( n  =  13/14 ) in the chronic phase . in contrast , the non - cs population had a mortality rate of 36  % ( n  =  4/11 ) in the acute phase , which remained the same in the chronic phase . this case series was particularly useful due to the fact that all patients were directly treated when the vsr was diagnosed , independent of haemodynamic stability . this rules out any selection bias based on treatment delay and shows the importance of controlling cs before attempting vsr occlusion . percutaneous occlusion is a less invasive alternative to surgical treatment , thus making it especially valuable when surgical closure is not indicated . it is important to state that percutaneous occlusion is an option in every case where the decision to perform an intervention has been made , because transformation to the classic surgical approach is possible at any time . this technique is most successful when performed in the chronic phase after post - infarction vsr diagnosis . if shunts remain or residual shunts form , placement of multiple devices is possible . percutaneous occlusion is also successful in patients who present with clinically significant residual shunting in follow - up after initial successful closure [ 17 , 2123 ] . occlusion in the acute phase in haemodynamic unstable patients had the aim of permanently closing the vsr or stabilising the patient as a step - up approach to surgical treatment . percutaneous treatment of a vsr should always be considered when a patient refuses surgical treatment . the mechanism of origin of the vsr often results in a more complex anatomy , making complete closure difficult . apart from that , the device has to be placed in fragile necrotic tissue where every manipulation can lead to an increase of the vsr diameter and device displacement . persistent left - to - right shunting can be caused by progressive septal necrosis or by complications in relation to device placement . the presence of such a residual shunt differs greatly amongst the different authors ( 12.5100  % ) [ 1012 , 18 , 20 ] . when percutaneous treatment was performed , a variety of procedure - related complications occurred : device embolisation , left ventricle free wall rupture , cardiac arrhythmia , haematoma at the puncture side , haemolysis and dislodging of the occluding device . procedure - related complications did not occur frequently and were rarely the direct cause of mortality . complications not related to the procedure were multiple organ failure [ 11 , 12 , 16 , 18 ] , haemolytic anaemia [ 18 , 24 , 25 ] and sepsis . mortality occurring in the long - term period following intervention was often the result of one of these complications . percutaneous closure of a vsr is a feasible and a relatively safe technique when applied on carefully selected patients . in general complete occlusion was not always achieved but gross reduction in shunt fraction led to good results regarding mortality and post - intervention haemodynamic stability , thus proving its efficacy . following diagnosis , when percutaneous occlusion was applied in the acute phase ( < 14  days ) mortality rates varied strongly from 42  % to 100  % , despite high procedural success ( 5086.2  % ) . better results were obtained with treatment in the chronic phase ( 14  days ) , reducing the mortality rates to 2038.9  % . the most important risk factors concerning mortality were the presence of cardiogenic shock and treatment in the acute phase . further research with a larger patient populations is needed to assess the true value of percutaneous occlusion in post - ami vsr .
aimsthe aim of this systematic review is to gain insight into the published experience on percutaneous closure of a post - infarction ventricular septal rupture ( vsr).methodrelevant literature was obtained by mesh - term searches in the online search - engine pubmed . 
 articles published in the last 10  years were included . 
 further filtering was done by using search limits and individual article selection based on the aims of this systematic review.conclusionpercutaneous closure is a potential technique in a select group of patients . 
 the presence of cardiogenic shock and closure in the acute phase after vsr diagnosis are important risk factors of mortality . 
 device implantation is in general successful with few procedure - related complications . 
 reduction of the shunt fraction has been reported frequently . 
 this technique is a less invasive alternative to surgical treatment and should be applied on a case - by - case basis .