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Closure of perimembranous ventricular septal defects with aneurysmal tissue using the amplazter duct occluder I

Catheter-based perimembranous ventricular septal defect (VSD) closure with currently available devices implanted within the VSD is limited by the occurrence of postprocedure complete heart block. El Said and colleagues report herein their experience with percutaneous closure of perimembranous VSDs associated with aneurysm with the Amplatzer ADO 1 device. This follows their earlier report on three patients and describes the outcome over an observation period of up to 6 years (median 1.9 years) after device implantation. Particular attention is given to the absence of postprocedure complete heart block. The authors describe elegantly the anatomy of VSD with aneurysm and report implanting the Amplatzer ADO 1 device entirely within the aneurysm sac. Twenty-one patients (16 male) with perimembranous VSD and aneurysm underwent cardiac catheterization for the purpose of VSD closure using an ADO I. Nineteen patients had Amplatzer ADO I implantation. With two patients, device implantation was abandoned due to catheter-related conduction defects or arrhythmias. One device was misplaced resulting in significant residual shunt and hemolysis and was subsequently removed at the time of surgical VSD closure. Overall, 18 of 21 patients had satisfactory ADO 1 device implantation. At the last follow-up, complete VSD closure was noted in 11/19 patients. 4/19 had trivial residual shunt and 3/19 had mild residual shunt. Tricuspid insufficiency lessened after device placement in 5/19 patients. Periprocedural complications included one patient with a small pericardial effusion, accelerated junctional rhythm (4/19), ventricular tachycardia (1/19), new tricuspid insufficiency (1/19), and new tricuspid stenosis (1/19). All resolved over the follow-up period. Perhaps of more concern, new trace aortic valve insufficiency developed in 3/19 patients. Complete heart block was not observed. The authors stress that further studies are required before firm conclusions about the efficacy and safety of this approach are possible. Detailed follow-up of patients with a device implanted remains essential as we develop more understanding of potential late device-related complications. El Said and colleagues are to be commended for sharing their experiences which add to our understanding of perimembranous VSD with aneurysm. This report serves to remind us of the highly variable anatomy and that specific anatomic features must be taken into account during device closure of perimembranous VSD. The goal remains to repair VSDs with the least possible morbidity, whether by surgery or by device closure. Specific procedural difficulties highlighted in this report are likely to be overcome as device and delivery system development progresses.