Cardiogenic shock complicating extensive infarction with ventriculor. Septal defect: Circulatory assistance ana cardiac transplantation.

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.