A 47 year old man had a massive anterior myocardial infarction with cardiog
enic shock with a left parasternal murmur. Coronary angiography showed occl
usion of the left anterior descending artery for which angioplasty resulted
in failure. There was antero-lateral-apical akinesia and a ventricular sep
tal defect (VSD) with a left-right shunt (Qp/Qs = 1.54). Persistence and ag
gravation of haemodynamic instability led to intra-aortic balloon pumping w
ith inotropic pharmacological support followed by biventricular assistance
with a MEDOS device.
Under transoesophageal echocardiographic monitoring, the outcome was marked
over 7 days by the progressive increase in the shunt volume of the VSD, a
decrease of drainage and injection flow, progressive increase in spontaneou
s contrast echos followed by the presence of fibrin in the cardiac chambers
and canulae. the presence of thrombus in the external ventricles, blockage
of the right external valve which only opened after increasing the degree
of anticoagulation, and, finally, cardiac tamponnade which required drainag
e before the patient's state improved.
On the 8th day, the patient being stable with a normal neurological status,
the availability of a donor heart led to the decision to transplant, which
was carried out without complications. This case poses the problem of card
iac assist devices and their daily monitoring, and then that of cardiac tra
nsplantation in this indication.