Transcatheter closure of ventricular septal defect in aortic valve prolapse and aortic regurgitation

Abstract

Objective: To report intermediate follow-up result of transcatheter closure of ventricular septal defect (VSD) in presence of aortic valve prolapse (AVP) with or without aortic regurgitation (AR).

Method: This is a retrospective review of 19 patients with VSD with AVP with AR who underwent transcatheter closure in between September 2011-July 2014. Mean age was 8 years (1-16 years, standard deviation [SD] 4.08 years) and mean weight was 26.03kg (9-81.5kg, SD 16.57kg). Among them 2 had subarterial VSD, 6 had subaortic VSD and 11 had perimembranous VSD. All of them had mild AVP and 13 of them had AR (trivial or mild). Median VSD size was 4.3mm (4-6mm). Transcatheter closure was done either by retrograde technique using the Amplatzer Duct Occluder-II in 17 patients or antegrade technique using the Duct Occluder-I in 2 cases. Mean follow-up period was 18 months (12-36 months).

Result: Immediate major complications were encountered in 2 (10.5%) cases. Significant aggravation of device related AR was seen in one case & device embolised to right pulmonary artery in another case and both of them were managed surgically. During follow up, 1 child had significant additional VSD requiring device closure. One child developed moderate AR, requiring surgery. None of the other had shown any increase in severity of AR.

Conclusion: Device closure of VSD in presence of mild AVP and mild AR appears to be safe. Longer follow-up is necessary to draw final conclusion.

Keywords: Aortic regurgitation; Aortic valve prolapse; Device closure; Transcatheter technique; VSD.

Fig. 1

Pre-procedure Echocardiogram- Parasternal long axis view showing subaortic ventricular septal defect (VSD) (white arrow) with deficient subaortic rim (1A), Parasternal long axis cranially tilted view showing subpulmonic VSD (white arrow) (1B), Parasternal long axis view showing prolapsed right coronary cusp of aortic valve (red arrow) (1C).

Fig. 2

Left ventriculogram to profile VSD- left anterior oblique (50°) cranially tilted (20°) view showing small subaortic VSD (white arrow) (2A), prolapsed right coronary cusp of aortic valve (white arrow) (2B), left anterior oblique (75°) cranially tilted (20°) view showing small doubly committed subarterial VSD (thick white arrow) (2C), right anterior oblique (30°) cranially tilted (30°) view showing small doubly committed subarterial VSD (white arrow) (2D).

Fig. 3

Technique of VSD devioce closure- antegrade technique- device is across the VSD from right ventricular side (3A), retrograde technique- catheter is across the defect from left ventricular side (3B), left ventriclogram before releasing the device during VSD closure by antegrade technique showing the left ventricular disc of the device (white arrow) is away from aortic valve cusp (black arrow) (3C), dye injected through the guiding catheter before releasing the device in retrograde technique showing device (white arrow) is under the aortic valve (black arrow) but not impinging on it (3D).

Fig. 4

Transthoracic echocardiogram after the procedure- parasternal long axis view showing the device (white arrow) is bending to the plane of aortic valve (red arrow) without impinging on it (4A), colour Doppler image showing the device (white arrow) is sitting under the aortic valve which is coapting normally in diastole without any aortic regurgitation (4B), parasternal short axis view of aortic valve in a case of doubly committed subarterial VSD showing the device (white arrow) is in very close proximity to the pulmonary valve (red arrow) which is coapting normally (4C), colour Doppler image showing the device (thin arrow) near right coronary cusp of aortic valve with trivial aortic regurgitation (thick arrow) following the closure of subaortic VSD with (4D).