• Users Online: 102
  • Print this page
  • Email this page

Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 324-329

Retrograde transcatheter closure of perimembranous aneurysmal ventricular septal defects using amplatzer vascular plug II

1 Department of Cardiology, National Heart Institute, Giza, Egypt
2 Department of Cardiothorasic Surgery, National Heart Institute, Giza, Egypt
3 Department of Anathesiology, Ahmed Maher Hospital, Giza, Egypt

Date of Web Publication10-Feb-2020

Correspondence Address:
Rania Diaa Abou Shokka
Department of Cardiology, National Heart Institute, Giza
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JMISR.JMISR_63_19

Rights and Permissions

Retrograde transcatheter closure of perimembranous aneurysmal ventricular septal defects (pmVSD) can be a better option for transcatheter closure of ventricular septal defect with device placement into ventricular septal aneurysm with fewer complications. Also, a retrograde approach might decrease procedure time and radiation exposure time.
The purpose of this study was to report off-label experience using Amplatzer Vascular Plug II (AVPII) for the trans catheter closure of perimembranous aneurysmal VSD. Comparison of haemodynamic effects of ketamine and sevofluorane as in induction of anesthesia.
Materials and methods
Our series consists of a fifteen child with pmVSD. The mean age was 4.9 years (range: 1.2–10 years), mean left ventricular end-diastolic dimension 38.3 mm. Maximum and minimum defect sizes were 4 and 8 mm by transthoracic echocardiography (mean defect size: 5.2 mm). The procedure was performed under general anesthesia with left heart catheterization for retrograde closure of the defect. The study was done on 15 children from 2016 to 2018 for retrograde transcatheter closure of aneurysmal perimembrance VSDs using an Amplatzer vascular plug II Baseline characteristics of the study patients are set in Table I. All the children who had aneurysmal perimembrance outlet ventricular septal defect with left to right shunt were included for assessment of closure. The children eligiable underwent clinical evaluation that also included electrocardiogram (ECG), and standard echocardiography assessment.
All participants who met the inclusion criteria were sent to the catheterization laboratory. Following left ventricular angiogram, three patients were excluded as technically nonfeasible. Failure to cannulate the defect in one patient and deficient aneurysmal tissue during left ventricular angiography in two cases. The device was successfully deployed in 12 children with the retrograde technique. In two patients antegrade approach was used using the ADO I device due to deficient aneurysmal tissue. The complete VSD closure rate was 84% immediately, 92% at 24 h, and 92% at the last follow-up. Atrioventricular conduction system was not affected by the procedure in any patients. Arterial complication developed in two patients. There was no device embolization; no aortic regurge developed in any patient. According to children had ketamine in induction of anesthesia HR recorded (122±16) beats /min but the children had sevofuran in indnction of anestherin re corded (108±12) beats/min but not significant different howevere the (MBP) inth children had ketamin had (68±14) mm Hg but the children had sevofluran in induction (60±8) mm Hg but not significant different.
Retrograde transcatheter closure of pmVSDs using AVPII is a safe and effective alternative method which allow closure of a wider range of VSDs due to availability of wide ranges of AVPII sizes of up to 22 mm in diameter. The retrograde approach can also simply the procedure with less fluoroscopy time and anesthesia time.

Keywords: Perimembranous, septal aneurysm, transcatheter

How to cite this article:
Abou Shokka RD, Al Gebaly AA, Hossam WM. Retrograde transcatheter closure of perimembranous aneurysmal ventricular septal defects using amplatzer vascular plug II. J Med Sci Res 2019;2:324-9

How to cite this URL:
Abou Shokka RD, Al Gebaly AA, Hossam WM. Retrograde transcatheter closure of perimembranous aneurysmal ventricular septal defects using amplatzer vascular plug II. J Med Sci Res [serial online] 2019 [cited 2020 Apr 6];2:324-9. Available from: http://www.jmsr.eg.net/text.asp?2019/2/4/324/278071

  Introduction Top

Ventricular septal defects (VSDs) are one of the most common forms of congenital heart defects accounting for about 20% of defects in isolation[1].

Yilmaz and colleagues have reported that perimembranous aneurysmal VSD (pmVSD) was found in 20% of perimembranous VSDs[2] that can progress in infancy to a functionally smaller defect with aneurysmal formation[3], which reduces the VSD size and allows transcatheter closure with fewer complications.

Introduction of amplatzer family of devices has markedly widened the scope of transcatheter closure of these defects[4], especially device closure of pmVSDs which has been complicated with unpredicted episodes of conduction block[5],[6] in 20–30% of cases due to the proximity of conduction fibers to the margins of the defect. The mechanism of conduction block is likely related to local myocardial inflammation as the most common cause due to the self-expanding Nitinol devices that exert expansive force on the margins of the defect. An alternate method of device placement has been described, in which the occluder device is implanted into the ventricular septum aneurysm[7],[8]. In this position, the device is remote from the conduction system and aortic valve. Retrograde transcatheter device closure of VSD has been described in some studies [9–11] when the antegrade approach had failed using the venous route. This approach is simple as it avoids the circuitous route of antegrade approach by femoral vein with the use of large stiff delivery sheaths, which may cause hemodynamic instability while crossing the tricuspid valve, the defect or the aortic valve, and also shortens the total procedure time, decrease radiation exposure to the patient and operators, and decrease the procedure cost, which represents an important issue in developing countries.

  Aim Top

The purpose of this study was to report our off-label experience using Amplatzer Vascular Plug II (AGA Medical Corp., Golden Valley, Minnesota, USA) for retrograde closure of pmVSD.

  Materials and Methods Top

The study was done on fifteen children from 2016 to 2018 for retrograde transcatheter closure of pmVSDs using an AVPII. Baseline characteristics of the study patients are set in [Table 1]. All the children who had aneurysmal perimembranous outlet VSD with left to right shunt were included for assessment of closure. The children eligible underwent a clinical evaluation that also included an ECG and standard echocardiography assessment.
Table 1: Clinical and Demographic of patients in the study

Click here to view

Inclusion and exclusion criteria

In all pmVSD patients, transcatheter closure was indicated for hemodynamic symptomatic or other medical reasons. All patients were evaluated by transthoracic echocardiography (TTE) with GE Vivid 5 (GE Healthcare, USA).

Exclusion criteria

Defects associated with other cardiac lesions requiring a surgical approach:

  1. Inlet and doubly committed VSD.
  2. pmVSD with a bidirectional or predominant right to left shunt through the VSD on color Doppler (irreversible pulmonary hypertension).
  3. More than mild aortic regurgitation.
  4. Aortic valve prolapsed.

Inclusion criteria

  1. Symptoms and signs of heart failure.
  2. Failure to thrive.
  3. Frequent respiratory infection (defined as >6 events in 12 months).
  4. The cardiothoracic ratio of more than 0.5 with increased pulmonary vascularity on chest radiography.
  5. History of infective endocarditis.
  6. Age more than 1 year.


AVPII is nitinol braided in two layers in the smaller devices and three layers in devices bigger than 10 mm. It is available in diameters starting at 3 mm, ranging from 4 to 22 mm in 2 mm increments. It is available in lengths ranging from 6 to 18 mm and is deployed through 5–9-Fr guiding catheters.

Device implantation

The catheterization procedure was performed under general anesthesia with tracheal intubation. Heparin (100 IU/kg) was administered intravenously during the procedure. Approximately 30 min before device implantation prophylactic antibiotics were administered, and an additional dose was given 8 h later. Based on the quality of the image, TTE was selected to guide deployment. Access is through the right or left femoral artery puncture. Angiography in the left ventricle (LV) at a 55°/20° left anterior oblique projection/cranial was used to profile the pmVSD. Location, size of the pmVSD, and its relationship with the aortic valve were assessed. Each pmVSD was categorized by its shape as tubular, window-like, and aneurismal type. The diameter of the pmVSD was measured at the largest diastolic phase, and an occluder size was selected based on this measurement [Figure 1].
Figure 1: Sizing of aneurysmal VSD defect (LV inlet & RV outlet) diameters in left ventricular angiograms in long-axial oblique projections for device selection

Click here to view

Device selection

The waist diameter of the chosen AVPII was approximately equal to the right ventricular (RV) outlet of the aneurysm or greater by 1–2 mm in single RV outlet. In fenestrated aneurysmal defect device diameter was selected according to the LV inlet diameter of VSD as a device used to close the inlet of the defect.

Deployment of the device

The defect was passed using a 0.035-inch hydrophilic Terumo wire and then a 6 Fr Right Judkins or Amplatzer Right catheter was introduced over the Terumo wire and then exchanged with a super-stiff exchangeable wire. The guiding catheter advanced to the RV over the wire where the wire was removed and the guiding catheter was loaded with the device. The right retention disk of AVPII was deployed, and the assembly is withdrawn so that the disk was aligned with the septum guided by TTE [Figure 2]. The waist and left retention disk were then sequentially deployed within the left side of the aneurysm. Once a stable position and no interference with aortic and tricuspid valves were confirmed with TTE in apical five-chamber and parasternal short axis and subcostal views; LV injection was done in the left anterior oblique view to visualize accurate closure with no residual flow across te device, then the delivery system was detached and removed together with the guiding catheter [Figure 3]. Left ventriculography showed minimal intradevice residual shunting in two patients. TTE revealed both retention disks to be flat and in an appropriate position without interference with the aortic valve. Aorta root injection was performed after closure to verify any new-onset aortic valve regurgitation. Continuous ECG monitoring was used during the first 24 h after the procedure. The patient received Aspirin (5 mg/kg daily) for the first 6 months in all patients.
Figure 2: Device deployment guided by trans thoracic echocardiography

Click here to view
Figure 3: A left ventricular angiogram (long-axial oblique projection) obtained after release of the device with absence of residual shunt

Click here to view

Follow-up evaluation

All patients were evaluated before discharge with physical examinations, ECGs, and echocardiograms. Also, all patients were referred for follow-up, which occurred at a median time of 6 months.

Echocardiography follow-up

Immediate postprocedural echocardiogram was done to all patients. Despite trivial to small residual VSD shunting in two patients, there was an acute reduction in LV size in all patients and tricuspid regurge.

Late complications and analysis

Two patients developed femoral artery thrombosis documented by duplex that required anticoagulant therapy with continuous intravenous heparin infusion for 3 days and then continued on subcutaneous Clexane for 1 week, where signs and symptoms improved and duplex document recanalization of the thrombus.

  Results Top

All participants who met the inclusion criteria were sent to the catheterization laboratory with the intention to treat the defect percutaneously. Fifteen patients (nine women, 60% and six men, 40%) were eligible for the procedure [Table 1].

Their ages ranged from 1.4 to 10 years (mean: 4.5 ± 2.9 years). All patients have pmVSD by transthoracic echo with VSD diameter (RV end) with TTE mean of 5.3 ± 1.3 mm. In eight (66.7%) patients, there were single RV outlet VSD while in four (33.3%) patients number 1, 2, 5, and 8; fenestrated ventricular septal aneurysm (VSR) was also seen. In patient number 1 there was fenestrated ventricular septum aneurysm with two RV outlet defects 5 and 3 mm during LV angiography, and AVPII size 10 was used to close inlet of the defect; also patient number 2 has two RV outlet VSD (6 and 3 mm) during LV angiography where AVPII size 12 was selected for closure of LV outlet of defect. Failure for retrograde closure using AVPII was in two patients. In patient number 14 there was a failure to cross the defect with Terumo wire due to the small size of the defect (3 mm in diameter) with prolongation of the procedural time. In patient number 13 and 15, there were deficient aneurysmal septal tissues during LV angiography, so antegrade procedural with a venous circuit using Amplatzer Duct Occlude I size 8/6 in patient number 15 and device size 6/4 in patient number 13.

The most commonly used is AVPII size 8 in five (41.7%) patients followed by size 6 in three (33.3%) patients, size 10 (in two patient 16.7%) and device size 12 in one patient (8.3%) in [Table 2]. Our mean fluoroscopic time was 26.8 ± 3.7 min. Fine residual leaks were observed in two patients by angiography and TTE immediately after the device closure with trivial residual leakage observed in one patient after 24 h and in follow-up period by TTE after 3 months. The complete VSD closure rate was 84% immediately after the procedure, 92% at 24 h and 92% at the last follow-up. The mean LV end-diastolic dimension of the patients was 38 ± 5.4 mm before VSD closure and 32 ± 5.9 mm after closure (P = 0.0001), mean LA dimension 26 ± 4.4 mm before closure and 21 ± 3.5 mm after (P = 0.0001).
Table 2: Echo versus Angiography for defect sizing

Click here to view

A reduction of pre-existing TR was seen in all children after VSD closure, with a mean TR of 24.7 ± 8 and 8.9 ± 1.7 mmHg after closure (P = 0.003) as it was converted to a normotensive (normal calculated RV systolic pressure) TR.

There was no incidence of left bundle branch block, P-Q prolongation, or CHB during the follow-up evaluation. There was no evidence of aortic regurgitation in any of the cases by echocardiogram. Arterial complication developed in two (16.7%) patients in the form of femoral artery thrombosis that was treated with intravenous heparin infusion and relief of symptoms and signs in the follow-up period. There was no device embolization nor aortic regurge develop in any patient.

  Discussion Top

AVPII device received FDA approval for use in September 2007 for a various procedure with numerous published reports describing their utility for vascular occlusion procedures, including peripheral vasculature[12], pulmonary AVMs[13],[14], aortopulmonary collaterals[15], and patent ductus arteriosus[16],[17].

Our study group is limited to those with VSDs with aneurysmal septal tissue to deploy the device within the aneurysm as pmVSD, as MSA is devoid of any component of the conduction system[18],[19] apart from aortic valve and conduction tissue for less complications as reported mostly in complete heart block[8],[11].

In the current case series, the retrograde technique was implemented successfully in 12 patients except in three patients. In one patient out of these three patients, there was failure to cannulate the defect with a prolonged procedural time which is also reported by Jameel et al.[20].

In or direct retrograde approach, the delivery system is advanced over the long exchangeable wire without creating an AV loop and passing the defect from the LV side and avoids fewer steps compared with the antegrade technique. The authors accept that transcatheter VSD closure is considered one of the interventional procedures with a high level of difficulty[21].

In a large case series reported by experienced centers indicate considerably prolonged fluoroscopy and procedure times in some cases. For example, the maximum procedure time was 300 and 342 min in the European registry[22] involving 403 cases and in a single-center Chinese study[23] conducted on 848 cases.

This technique seems to reduce the fluoroscopy time and radiation exposure of the operator and the patient, and cost of the procedure as the long delivery sheath is replaced by a guiding catheter and there is no need for snare as in the retrograde approach there is direct device deployment without the need for an arteriovenous circuit.

While the small diameter of the arterial vessels in infants poses an obstacle for the selection of the retrograde approach, in our study using the guiding catheter changes as delivery systems for AVPII device allowed the use of transarterial implantation technique without possessing this obstacle.

Recently, with this technique, the Amplatzer muscular occlude device[20],[24] and ADO II device[25] have been implanted successfully in adolescents and children with congenital VSD.

When comparing our study to two pediatric series [Table 3] that employed a technique similar to ours, our timings were somewhat longer than the figures in the study by Koneti et al.[25] and shorter than that reported in the study by Jameel et al.[20].
Table 3: Comparesion with previous studies

Click here to view

The retrograde implantation technique was easily employed in the majority of our cases, as the fluoroscopy time ranges from 18 to 40 min with a mean of 27.6 min.

Pooling data from the literature, Butera et al.[26] calculated the mean rate of successful closure at 96.3%, while in our study, we had a comparable VSD closure rate of 92%. None of our patients developed CHB during the procedure or follow-up period compared to Carminati et al.[22] who noticed a 2.5% occurrence of acute (within 48 h) and late-onset (at 5 and 12 months postprocedure) complete heart block in Amplatzer device closure of pmVSD[27]. None of our patients developed CHB during the procedure or follow-up so far.

  Conclusion Top

The results of the present study suggest that the retrograde approach may be implemented successfully in pmVSD closure without creating AV loop in children patients. However, the morphological features of the defect, including aneurysmal septal aneurysm, is important in selecting patients for transcatheter closure using AVPII. This technique is simple and easy, without the need for arteriovenous loop, which in turn reduces the fluoroscopy time; also, AVPII appears to be cheaper than the devices compared using this technique. However, usage in a larger series of pmVSDs and a longer period of follow-up is needed to detect the development of late conduction abnormalities. Using of ketamine in induction of anesthesia in children under cardiac surgery maintains haumodynamic stalility and easily available.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

McDaniel NL, Gutgesell HP. Ventricular septal defects. In: Allen HD, Driscoll DJ, Shaddy RE, Feltes TF, editors. Moss and Adams' Heart Disease in Infants, Children, and Adolescents. 7th ed. Baltimore, MD: Williams and Wilkins; 2008. 667–682.  Back to cited text no. 1
Yilmaz AT, Ozal E, Arslan M, Tatar H, Ozturk OY. Aneurysm of the membranous septum in adult patients with perimembranous ventricular septal defect. Eur J Cardiothorac Surg 1997; 11:307–311.  Back to cited text no. 2
Moe DG, Guntheroth WG. Spontaneous closure of uncomplicated ventricular septal defect. Am J Cardiol 1987; 60:674–678.  Back to cited text no. 3
Gu X, Han YM, Titus JL et al. Transcatheter closure of membrance ventricular septal defects with new nitinol prosthesis in a natural swine model. Catheter Cardiovasc Interv 2000; 50:502–509.  Back to cited text no. 4
Sullivan ID. Transcatheter closure of perimembranous ventricular septal defect: Is the risk of heart block too high a price? Heart 2007; 93:284–286.  Back to cited text no. 5
Oses P, et al. Treatment of isolated ventricular septal defects in children: Amplatzer versus surgical closure. Ann Thorac Surg 2010; 90:1593–1598.  Back to cited text no. 6
Butera G, et al. Transcatheter closure of perimembranous ventricular septal defects; early and long-term results. J Am Coll Cardiol 2007; 50:1189–1195.  Back to cited text no. 7
Fu YC, et al. Transcatheter closure of perimembranous ventricular septal defects using the new amplatzer membranous VSD occluder. J Am Coll Cardiol 2006; 47:319–325.  Back to cited text no. 8
Hijazi ZM, Hakim F, Al-Fadley F, Abdelhamid J, Cao QL. Transcatheter closure of single muscular ventricular septal defects using the amplatzer muscular VSD occlude: initial results and technical considerations. Catheter Cardiovasc Interv 2000; 49:167–172.  Back to cited text no. 9
Szkutnik M, Kusa J, Bialkowski J. Percutaneous closure of perimembranous ventricular septal defects with Amplatzer occluders – a single-center experience. Kardiol Pol 2008; 66:941–947.  Back to cited text no. 10
Holzer R, Balzer D, Lock Qi-Ling Cao K, Hijazi ZM. Device closure of muscular ventricular septal defects using the Amplatzer muscular ventricular septal defect occluder. Immediate and mid-term results of a US registry. J Am Coll Cardiol 2004; 43:1257–1263.  Back to cited text no. 11
Yang J, Yang L, Yu S, Liu J, Zuo J, Chen W, et al. Transcatheter versus surgical in children: a randomized controlled trial. J Am Coll Cardiol 2014; 63:1159–1168.  Back to cited text no. 12
Tuite DJ, Kessel DO, Nicholson AA, Patel JV, McPherson SJ, Shaw DR. Initial clinical experience using the amplatzer vascular plug. Cardiovasc Interv Radiol 2007; 30:650–654.  Back to cited text no. 13
Farra H, Balzer DT. Transcatheter occlusion of a large pulmonary arteriovenous malformation using the amplatzer vascular plug. Pediatr Cardiol 2005; 26:683–685.  Back to cited text no. 14
Santos CS, Norte A, Ferreira I, et al. Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations – embolization with Amplatzer vascular plug. Rev Port Pneumol 2009; 15:331–337.  Back to cited text no. 15
Hijazi ZM. New device for percutaneous closure of aortopulmonary collaterals. Catheter Cardiovasc Interv 2004; 63:482–485.  Back to cited text no. 16
Glatz AC, Petit CJ, Gillespie MJ. Novel use of a modified amplatzer vascular plug to occlude a patent ductus arteriosus in two patients. Catheter Cardiovasc Interv 2008; 72:82–86.  Back to cited text no. 17
Fischer G, Apostolopoulou SC, Rammos S, Schneider MB, Bjornstad PG, Kramer HH. The Amplatzer membranous VSD occluder and the vulnerability of the atrioventricular conduction system. Cardiol Young 2007; 17:499–504.  Back to cited text no. 18
Lock JE, Block PC, McKay RG, Baim DS, Keane JF. Transcatheter closure of ventricular septal defects. Ciculation 1988; 78:361–3687.  Back to cited text no. 19
Jameel AA, Arfi AM, Arif H, Amjad K, Omar GM. Retrograde approach for device closure of muscular ventricular septal defects in children and adolescents, using the Amplatzer muscular ventricular septal defect occluder. Pediatr Cardiol 2006; 27:720–728.  Back to cited text no. 20
Holzer R, Balzer D, Cao QL, Lock K, Hijazi ZM; Amplatzer Muscular Ventricular Septal Defect Investigators. Device closure of muscular ventricular septal defects using the Amplatzer muscular ventricular septal defect occluder: immediate and mid-term results of a US registry. J Am Coll Cardiol 2004; 43:1257–1263.  Back to cited text no. 21
Carminati M, Butera G, Chessa M, De Giovanni J, Fisher G, Gewillig M, et al.; Investigators of the European VSD Registry. Transcatheter closure of congenital ventricular septal defects: results of the European Registry. Eur Heart J 2007; 28:2361–2368.  Back to cited text no. 22
Yang J, Yang L, Wan Y, Zuo J, Zhang J, Chen W, et al. Transcatheter device closure of perimembranous ventricular septal defects: midterm outcomes. Eur Heart J 2010; 31:2238–2245.  Back to cited text no. 23
Muthusamy K. Retrograde closure of perimembranous ventricular septal defect using muscular ventricular septal occluder: a single center experience of a novel technique. Pediatr Cardiol 2015; 36:106–110.  Back to cited text no. 24
Koneti NR, Penumatsa RR, Kanchi V, Arramraj SK, S J, Bhupathiraju S. Retrograde transcatheter closure of ventricular septal defects in children using the Amplatzer Duct Occluder II. Catheter Cardiovasc Interv 2011; 77:252–259.  Back to cited text no. 25
Butera G, Chessa M, Carminati M. Percutaneous closure of ventricular septal defects. Cardiol Young 2007; 17:243–255.  Back to cited text no. 26
Sun XJ, Gao W, Zhou AQ, Yu ZQ, Li F, Huang MR, Sun K. Risk factors for arrhythmia early after transcatheter closure of perimembranous ventricular septal defects. Zhonghua Er Ke Za Zhi 2005; 43:767–771.  Back to cited text no. 27


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded8    
    Comments [Add]    

Recommend this journal