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Ventricular septal defects (VSD) are the most common congenital heart disease. Of these defects 80% involves the membranous septum. With the introduction of eccentric perimembranous VSD (PmVSD) occluder devices, percutaneous closure of PmVSDs has become an accepted alternative to surgical closure. However, closure of PmVSDs associated with septal aneurysms is more challenging. We report our experience of device closure of PmVSD associated with septal aneurysm.
Between 2008 and 2012, percutaneous closure of PmVSD associated with a septal aneurysm was attempted in 11 patients in our institution. The indication for VSD closure was the presence of hemodynamically significant PmVSD demonstrated by cardiac catheterisation (Qp/Qs > 1.5). We used 2 methods to occlude PmVSD associated with septal aneurysm: 1) to close the defect at the left ventricular opening of the aneurysm by anchoring the left disc of the occluder at the the inlet portion of the aneurysm and compressing the aneurysm and the defect between the left and the right discs of the device; 2) to close the defect at the outlet by anchoring the left disc of the device at the left side of the outlet portion of the aneurysm. We preferred to use the first method when the aneursym was small and there is adequate distance from the aortic valve. The patients were followed up at 1st, 3rd, 6th and 12th months after the closure procedure by TTE and ECG.
Mean age of the patients was 36.2±1.3 and 64% were male. The demographic and clinical characteristics of patients are shown in table 1. The average diameter of the VSD was 5.9±2.4 mm by angiography. One patient had 2 defects within the aneurysm and 1 patient had dextrocardia. Large aneurysm (the inlet portion of the aneurysm > 10 mm) was present in 7 patients. The procedure was successful in all patients. We used Amplatzer PmVSD occluder device in 3 patients, Amplatzer Muscular VSD occluder device in 5 patients, Amplatzer Duct occluder-I (ADO-I) in 1 patient and ADO-II device in 2 patients. We prefered to occlude the defect by the first method in 4 patients who had a small aneurysm and PmVSD occluder was used in 3 cases and a muscular VSD occluder device was implanted in 1 patient. Second method was prefered in 7 patients who had larger aneurysms. A trivial residual shunt was detected by ventriculography in 4 patients immediately after the procedure. Complete closure was observed by transthoracic echocardiography in all patients at the time of discharge. The patients were followed-up at mean of 22±1.9 months. There was no device or procedure related complications at the acute setting or mid-term follow-up.
Percutaneous closure of PmVSDs associated with aneurysm is more challenging than simple defects. The selection of the device type and size should be made according to the configuration and size of the aneurysm and the defect.
|Gender||Age (years)||Qp/Qs||VSD size (mm)||Aneurysm inlet size (mm)||Device|
|Patient 1||Male||26||2.2||4||5||PmVSD occluder|
|Patient 2||Female||18||2||8||18||Muscular VSD occluder|
|Patient 3||Male||36||1.6||5||19||Muscular VSD occluder|
|Patient 5||Male||42||1.7||8||15||Muscular VSD occluder|
|Patient 6||Male||62||2||8||9||PmVSD occluder|
|Patient 8||Female||49||1.6||3||8||PmVSD occluder|
|Patient 9||Female||49||1.7||3||5||Muscular VSD occluder|
|Patient 11||Female||36||1.7||8||15||Muscular VSD occluder|
VSD: ventricular septal defect ADO: Amplatzer Duct Occluder