Ventricular septal defect in association with left ventricular aneurysm formation has been reported rarely. Quinn and Brady (Heart 2002;87:567) describe attempted surgical closure of such a defect that was unsuccessful. A 61 year old man presented with a very similar defect 10 days after inferoseptal myocardial infarction. He was referred to our centre for consideration of surgical closure but deteriorated further with ventricular dysrhythmia, renal impairment, and hepatic congestion (AST 2078 units). An intra-aortic balloon pump was inserted with clinical improvement and surgery was considered. Transthoracic echocardiography demonstrated a large defect in the basal part of the muscular ventricular septum with an aneurysm bulging into the right ventricle. The aneurysmal portion was perforated (panel A, arrow) with colour flow Doppler studies demonstrating a significant left to right shunt (panel B). Coronary angiograms showed occlusion of only the left ventricular branch of the right coronary artery.

There was concern about a surgical approach through the left ventricle partly because the territory of either the patent left anterior descending artery or the patent posterior descending artery would be sacrificed and partly in view of the recent unfavourable report in Heart.

A percutaneous approach was therefore undertaken. The defect in the ventricular septum itself was too large to accept a device. After balloon sizing via a complete arterio-venous loop (from the right femoral artery across the defect to the right internal jugular vein), an 18 mm Amplatzer muscular ventricular septal defect closure device (AGA Medical Corporation, USA) was deployed into the largest perforation in the aneurysmal portion (panel C).

The aortic systolic pressure immediately increased by approximately 20 mm Hg, the intra-aortic balloon pump was removed at 24 hours, and the patient was discharged home at seven days. At two months follow up, he remained well and was walking 2–3 miles per day. Repeat transthoracic echocardiography demonstrated no flow across the device, but there was a residual shunt adjacent to it (panel D), which may require a second device.