Transfemoral Occlusion of Doubly Committed Subarterial Ventricular Septal Defect Using the Amplatzer Duct Occluder-II in Children

Abstract

Backgrounds: The traditional treatment of doubly committed subarterial ventricular septal defect (dcVSD) is open-heart surgery. This study aimed to evaluate the feasibility, safety, and outcome of transcatheter closure of small dcVSD using Amplatzer duct occluder-II (ADO-II) in children.

Methods: Between January 2016 and April 2021, 24 children (17 male and 7 female patients) with small dcVSD who received transfemoral closure with ADO-II were enrolled retrospectively. All of their available clinical and follow-up data were evaluated.

Results: The patients' median age was 3.2 years (1.6-12.6 years, 4.2 ± 3.1 years) and body weight was 13.3 kg (10.0-38.5 kg, 16.5 ± 7.7 kg). Left ventricular angiography showed that the median dcVSD size was 2.0 mm (1.5-3.5 mm, 2.1 ± 0.6 mm). The device was successfully implanted in 23 patients (95.8%), and one patient failed to be closed because of the underestimation of defect size due to preoperative aortic valve prolapse, with 16 patients by the antegrade approach and eight patients by retrograde approach. The diameters of the device used were 3/4, 4/4, and 5/4 mm. The median operative time was 40.0 min (20.0-75.0 min, 41.7 ± 13.7 min), and the median fluoroscopic time was 5.0 min (3.0-25.0 min, 6.8 ± 5.0 min). With a follow-up duration of 1+ to 45+ months, only 1 patient presented with new-onset mild aortic regurgitation (AR).

Conclusion: Transfemoral closure of small dcVSD with ADO-II is technically feasible and safe in the selected children. However, the development or worsening of AR requires long-term follow-up.

Keywords: Amplatzer duct occluder-II; children; doubly committed; subarterial ventricular septal defect; transfemoral closure.

Figure 1

The confirmed diagnosis of dcVSD by TTE. Parasternal short-axis view (A,B) on TTE shows the dcVSD located at the 1-2 o'clock position (arrows). AO, aortic; LA, left atrium; RV, right ventricle; RA, right atrium; PA, pulmonary artery; dcVSD, doubly committed subarterial ventricular septal defect; TTE, transthoracic echocardiography.

Figure 2

The procedure of transfemoral occlusion of the dcVSD using the ADO-II device via the retrograde approach. (A) Confirms the location of the deVSD (arrow) by left ventriculography before device closure of it, and (B) Demonstrates the finding of aortography without AR before the procedure. (C–F) Show the processes of the transcatheter technique. (G) Shows the operational success and no RS by left ventriculography, and (H) Shows no AR after device implantation by aortography. dcVSD, doubly committed subarterial ventricular septal defect; AR, aortic regurgitation; RS, residual shunt.

Figure 3

The procedure of transcatheter closure of the dcVSD using the ADO-II device via the antegrade approach. (A) Confirms the location of the dcVSD (arrow) with left-to-right shunting on left ventriculography before the procedure. (B–E) Show the whole processes of the transcatheter technique. (F) shows the operational success and no significant RS by left ventriculography, and (G) Shows no AR after device implantation by aortography before releasing the occluder. (H) Demonstrates the good position and configuration of the released occluder under X-ray fluoroscopy. dcVSD, doubly committed subarterial ventricular septal defect; AR, aortic regurgitation; RS, residual shunt.

Figure 4

The images of TTE and angiography of case 12. (A,B) shows the dcVSD and the mild AVP on TTE. (C) Shows the mild AVP by left ventricular angiography. (D) Demonstrates the closure using ADO-II and (E) Shows the closure with symmetrical double-disk occluder. (F) Shows the AR after deploying occluder. AO, aorta; AR, aortic regurgitation; AVP, aortic valve prolapse; dcVSD, doubly committed subarterial ventricular septal defect; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; TTE, transthoracic echocardiography.