J INVASIVE CARDIOL 2019;31(4):E64-E65.
Key words: angiography, cardiac imaging, echocardiography, ventricular septal defect
A 63-year-old woman developed heart failure symptoms 1 year after successful mechanical aortic valve replacement and dual-chamber pacemaker implantation due to postoperative heart block. Transthoracic echocardiogram and transesophageal echocardiogram (TEE) revealed an 8 x 10 mm iatrogenic perimembranous ventricular septal defect (VSD) with left-to-right shunting (Figure 1A, Video 1). Percutaneous VSD closure was attempted under three-dimensional TEE guidance and general anesthesia after multidisciplinary heart team discussion.
The presence of a mechanical aortic valve made the traditional arteriovenous loop by retroaortic approach less preferable due to potential risk of catheter entrapment and hypotension. Attempts to cross the VSD from the right ventricle (RV) with a hydrophilic guidewire failed despite the use of a steerable Agilis catheter (St. Jude Medical), largely because of the unfavorable angulation and high-velocity left-to-right jet. Hence, we performed transseptal puncture and the left ventricular (LV) angiogram showed a funnel-shaped defect with smaller waist on the RV side (Figure 1B). The VSD was then crossed from the LV side and a novel venous-arteriovenous loop was established (Figures 2A and 2B; Videos 2 and 3). A 12 mm Amplatzer Perimembranous VSD Occluder (St. Jude Medical) was first chosen to close the defect (Video 4). During pull-back toward the VSD, the left-sided disc of the device inadvertently impinged the mitral valve leaflet, causing profound hypotension, which resolved after release of the tension in the delivery system (Figure 2C). In addition, the mechanical aortic valve leaflet motion was jeopardized due to device interference immediately after deployment (Figure 2D; Videos 5 and 6). Smaller 10 mm and 8 mm devices were tested with similar results. Finally, an 8/6 mm Amplatzer Ductal Occluder 1 (St. Jude Medical) successfully sealed the funnel-shaped defect (Figure 1G; Video 7). The device was pulled to better conform to the defect and thereby avoided interference with aortic valve function.
This case illustrates the feasibility of percutaneous closure of perimembranous VSD in a patient with mechanical aortic valve replacement utilizing a novel venous-arteriovenous loop, and emphasizes the importance of concomitant fluoroscopic and echocardiographic guidance in structural heart interventions.
Supplemental Videos Available here.
From the Division of Cardiology, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted October 26, 2018.
Address for correspondence: Dr Chak Yu So, Department of Medicine and Therapeutics, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, 30–32 Ngan Shing Street, Shatin, N.T., Hong Kong SAR. Email: firstname.lastname@example.org