There are still many limitations in a transcatheter closure of post-MI septal defect including the rigid delivery sheath that could tear the borders of VSD or dislocation of sheath into the right ventricle after wire removal. Also, currently available occluders are suboptimal.
I am afraid that post-MI VSD closure remains technically difficult.
A few propositions:
1. if your patient is stable and does not need any mechanical assist: balloon pump or ECMO: wait for a few weeks to allow the tissues tos heal or scar and avoid further tearing of the VSD.
2. If the VSD is located mid-septal or apical, choose the jugular approach.
3. If you decide to make a arteriovenous loop (which is often necessary), try to avoid strenuous traction and never leave your guide wire uncovered.
4. choose a large sheath (14 F) (kink resistant) and try to keep a guide wire in position while you advance the device or advance your sheath a little bit further in the LV
Overall, there are not many ways you can control delivery of the sheath or device during the procedure in order to avoid tearing a fresh MI-VSD
I would echo the comments above. keep the wire covered with a swan to avoid further fissuring of the defect. Most importantly, have a pediatric interventionalist with you as they are more experienced and can troubleshoot when things go wrong.
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