Author + information
- Ongkarn Komson1
Patient initials or identifier number
Relevant clinical history and physical exam
A 17-year-old man post Tetralogy of Fallot(TOF) surgical repair, complicated by post-operative liver failure, and renal failure required hemodialysis, who presented with recurrent heart failure. Echocardiogram revealed residual leaking between VSD patch and IVS. RHC showed an oxygen step up at RV and a Qp:Qs ratio of 2.1, mild RV infundibular stenosis (peak-to-peak gradient was 44 mmHg). PVR was 0.96 Wood units.The surgical assessment concluded the patient was at high risk.
Relevant test results prior to catheterization
Echo Echocardiogram revealed residual leaking between VSD patch and IVS.
Relevant catheterization findings
The RHC showed a oxygen step up at RV and a Qp:Qs ratio of 2.1, mild RV infundibular stenosis (peak-to-peak gradient was 44 mmHg). PVR was 0.96 Wood units.
Under general anesthesia, usingright femoral approach.
AJR(Terumo, Japan) 3.5 catheter wasplaced in the left ventricle(LV), then a 0.035” Glidewire(Terumo, Japan) used tocross the VSD into the right ventricle (RV) and subsequently advanced to thepulmonary artery. Glidewire successfully snared and then externalized via rightfemoral vein to create the arteriovenous (AV) loop. A 7Fr delivery sheath(Vascular Innovation, Thailand) advanced venously across the VSD and placed inthe ascending aorta. A 12-4 mm Cocoon VSD occlude (Vascular Innovation,Thailand) was advanced, and the left-sided disk was deployed and was pullingback against the IVS. The VSD occluder repeatedly slipped into the RV evenusing bigger (16-4 mm) device. After several attempts, we considered theretrograde delivery of VSD occluder from the femoral artery.
The 9Fr delivery sheath arteriallyadvanced over the AV loop. The defect crossed from the LV to RV. A 16-4 mmCocoon VSD occluder advanced and deployed successfully.
• TEE demonstrated no impingementof the aortic and tricuspid valves
• Left ventriculogram revealedminimal central flow across the device
• The device was released from thedelivery cable
• Final ventriculogram and TEEshowed minimal central flow through the device
• No paradevice leakage
• No heart block
The Percutaneous VSD closure could be the another option for the patients who may not be candidates for surgery ue to high surgical risk. The percutaneous VSD closure may be more difficult when the defect was located inferiorly to the VSD patch. Because of the soft part of the VSD patch, the both edges of VSD rim are not in the same plane (overriding aorta), a delivery sheath is not coaxial with the VSD axis. The retrogradely delivered VSD occluder is loaded from the left side (arterial side). It may help us to overcome this type of VSD.