1Deborah Heart & Lung Center, Browns Mills, New Jersey; 2Kaiser Permanente, Portland, Oregon
Disclosure: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Dr. Kintur Sanghvi at firstname.lastname@example.org.
A 30-year-old male with a past medical history of perimembranous ventricular septal defect presented for routine follow-up. A transthoracic echocardiogram was performed and revealed an aneurysmal perimembranous ventricular septal defect with a left to right shunt present with a peak velocity of 4.98m/sec and a peak left to right gradient of 99 mmHg. There was no evidence of aortic valve prolapse or aortic regurgitation. Compared to a prior echocardiogram 2 years ago, the left to right shunting appeared to be more prominent. Left ventricular systolic function was also mildly reduced, with left ventricular ejection fraction (LVEF) visually estimated at 50%. The patient was recommended for a left (LHC) and right heart cardiac catheterization (RHC) for further evaluation. The default accesses in our lab, the right radial artery and right basilic vein, were chosen for the LHC and RHC, respectively. The LHC showed right coronary
dominance and normal coronary arteries. LV angiography demonstrated a ventricular septal defect (VSD) (Figure 1) with a mildly dilated LV size and mildly reduced LVEF of 50%. The RHC revealed a step up in the oxygen saturation, 85% in the right ventricle and 76% in the right atrium. The final calculated ratio of pulmonary circulation to systemic circulation (Qp:Qs) was 1.8:1. In view of the LV morphology and functional changes, and evidence of moderate hemodynamic and angiographic shunts, it was recommended that the patient undergo percutaneous VSD closure.
The transesophageal echocardiogram (TEE) revealed a 7 mm perimembranous (pm)VSD presenting approximately 6 mm inferior to the aortic annulus. There was aneurysmal deformity of the defect extending into the right atrium. Color Doppler demonstrated continuous left to right flow through the defect from the left ventricle into the right ventricle (Figure 2). Right radial arterial access was achieved using a 5 French hydrophilic-coated sheet. A subcutaneous intravenous (IV) 21-gauge access in the basilica vein at the right cubital fossa was exchanged for a 5 French hydrophilic-coated sheet over a 0.021-inch wire. Heparin was used for anticoagulation to maintain an activated clotting time (ACT) of >250 seconds. We used a 5 French pigtail catheter to perform left ventriculography. Under fluoroscopy and TEE guidance, the pmVSD was crossed using a 5 French Judkins right 4 (JR4) diagnostic catheter and an angled
hydrophilic 0.035-inch Glidewire (Terumo) (Figure 3). The JR4 catheter was advanced into the right ventricle. The Glidewire was further advanced into the left pulmonary artery. A 5 French balloon-tipped Swan-Ganz catheter was floated to the left pulmonary artery from the right basilic vein access. The Swan-Ganz catheter was exchanged for an EN Snare device (Merit Medical) to the same level as the Glidewire in the left pulmonary artery (Figure 4). The Glidewire was then snared and externalized through the right basilic vein access site (Figure 5). Having an atrioventricular loop (Figure 6), we exchanged the short 5 French sheath in the basilic vein with a 7 French 90 cm long straight tip Destination sheath (Terumo) that was advanced from the basilic vein, across the VSD, across the aortic valve, and into the right subclavian artery (Figure 7). At this point, the 5 French pigtail catheter was inserted in the LV to provide angiographic guidance through the radial access. Under angiographic and TEE guidance, an 8 mm Amplatzer VSD occlusion device was deployed (Figure 8 and 9) in standard fashion (AGA Medical Corporation). The TEE showed excellent result with
no encroachment on the aortic valve and no residual left to right shunting. A vigorous “tug test” was performed and the device was stable. The device was released. Post-release TEE showed excellent alignment of the device into the ventricular septum and no disruption of the aortic valve (Figure 10). Repeat LV angiography showed no residual shunt across the VSD (Figure 11). The right radial sheath was removed using a hemostatic band and patent hemostasis technique. The 90 cm Destination sheath was removed from the basilic access and manual pressure was used to achieve hemostasis. The patient was monitored overnight in the cardiac care unit. Repeat follow-up transthoracic echocardiogram on the following day showed well-seated VSD occluder device that appeared without independent motion and without aortic regurgitation or left ventricular outflow tract (LVOT) obstruction. The patient was discharged home the next morning without any complications. He was seen in follow-up clinic 1 month after discharge, had been doing well, and denied any symptoms.
Ventricular septal defect (VSD) is a common congenital heart disease accounting for approximately 20% of all forms of congenital heart defects occurring in isolation.1-4 A VSD can be classified as muscular, perimembranous, or supra-crystal, depending on its location within the septum. Perimembranous is the most common form of VSD (70%).4 Indications for VSD closure include symptomatic congestive heart failure, signs of left ventricle overload, and a history of endocarditis. In patients with signs of left ventricle overload, VSD closure is performed to avoid pulmonary arterial hypertension, ventricular dysfunction, arrhythmias, aortic regurgitation, and development of a double-chambered right ventricle.4 Surgical closure has been the conventional treatment for VSDs, but is associated with morbidity and mortality.4 Percutaneous VSD closure has become an acceptable alternative to surgical closure.
In a large European VSD registry of 430 patients, the overall procedure success rate was 95.3% and mortality rate was 0.2%.4 A variety of devices were used for VSD closure in the registry. Currently, the most widely used device for closure of VSDs is the Amplatzer VSD Occluder. Reported technical success is 90% and risk of serious complication rate is low (8.6%), including complete atrioventricular (AV) block (4-5%), aortic insufficiency, and access-related complications ranging from 2-2.5%.4-7
Transcatheter VSD closure involves primary vascular access via a central vein with a secondary access via an artery. The closure device is loaded through the transvenous approach and the secondary arterial access is used to capture the guide wire. With advantages of lower access-related complications, improved morbidity, early ambulation, and overwhelming patient preference, the radial artery and basilic vein are an interesting and safer alternative to traditional femoral access. In our experience, crossing high pmVSDs is quite easy from the radial arterial approach using a JR4 catheter. The other advantage in using arm access is a shorter total length of the AV loop. The angle of delivery is similar to the approach from the right internal jugular vein. A basilic vein approach can be used for devices up to 12 mm in size. A larger device will require an 8 or 9 French sheath, which can be traumatic in the subcutaneous basilic or cephalic vein for some patients. A venogram can help to guide sizing of the vein. In many patients, an 8-9 French sheath may be reasonable in the basilic vein.
Here, we demonstrate that percutaneous closure of a pmVSD using transradial and basilic vein access can be successful, safe, and can avoid the potential risks of bleeding and vascular complications associated with the transfemoral approach.
- Hijazi ZM, Hakim F, Haweleh AA, Madani A, Tarawna W, Hiari A, Cao QL. Catheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: initial clinical experience. Catheter Cardiovasc Interv. 2002 Aug; 56(4): 508-515.
- Yang R, Sheng Y, Cao K, Kong X, Xu D, Yong Y, Zhou L, Zhang H, Qian L, Sun W, Gu Z. Transcatheter closure of perimembranous ventricular septal defect in children: safety and efficient with symmetric and asymmetric occluders. Catheter Cardiovasc Interv. 2011; 77(1): 84-90.
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- Yang R, Kong XQ, Sheng YH, Zhou L, Xu D, Yong YH, Sun W, Zhang H, Cao KJ. Risk factors and outcomes of post-procedure heart blocks after transcatheter device closure of perimembranous ventricular septal defect. JACC Cardiovasc Interv. 2012 Apr;5(4):422-427. doi: 10.1016/j.jcin.2012.01.015.
- Zhou T, Shen XQ, Zhou SH, Fang ZF, Hu XQ, Zhao YS, Qi SS, Li J, Lv XL. Complications associated with transcatheter closure of perimembranous ventricular septal defects. Catheter Cardiovasc Interv. 2008 Mar 1; 71(4): 559-563. doi: 10.1002/ccd.21412.