VSD are classified according to their location within the septum, however the most common type is the perimembranous type. Indications for perimembranous VSD closure are symptoms of heart failure, signs of left heart chambers volume overload, or a history of endocarditis. In patients with a volume overload of the left heart, closure is necessary to prevent pulmonary arterial hypertension, ventricular dysfunction, and arrhythmias.
The surgical approach is considered to be the gold standard, but it is associated with morbidity and mortality and the use of cardiopulmonary bypass. Percutaneous techniques have been developed, however possible complications of such a procedure might be the embolization or displacement of the device, arrhythmias, the hemolysis, the valvular insufficiency that can interest the aortic valve, tricuspid or mitral, pericardial effusion or the cardiac tamponade.
The most greater limit of the transcatheter closing of the VSD appeared in the approach to the perimembranous defects, for the risk of damage of the aortic valve: new techniques and new devices have allowed to also overcome this obstacle. Such risks increases significantly in residual VSD after previous surgical closure.
PDC is another alternative for perimembranous VSD closure, and initial reports have demonstrated excellent outcome of such a technique [2, 4, 5]. From the morphological aspect, a part of the margin of a perimembranous VSD is the area of fibrous continuity adjacent to the central fibrous body that bears the atrioventricular conduction bundle. These defects are in proximity to the aortic, tricuspid, or mitral valves. The previous studies have demonstrated a very low heart block rate [4, 5] differently to the percutaneous approach. Possible explanations may be device related, or delivery related. Whereas percutaneous techniques require a tortuous catheter path through the heart and ultimately through the VSD, the PDC approach allows for a device placement just from the “opposite” right ventricular free wall. Neither guidewires nor sheaths need to pass through in an angle, push and pull on perimembranous VSD margins.
The chosen device needs to be oversized as in our case by 2 millimeters. Since there was an extremely short route to the “area of interest”, a small step-up in size of the device allowed for a snug closure of the defect. Since the device had to close itself along the imaginary line (the line of the detached patch) passing from the posterior margin of perimembranous VSD, below the septal leaflet of the tricuspid valve and the subaortic upper point, we had to choose a device who could have a relatively small axis and a large biplane dimension as a multifenestrating atrial septal defects occluder (Amplatzer®).
We may conclude that PDC can be employed successfully in patients with residual perimembranous VSD after previous surgical repair as an alternative to the conventional surgery with excellent hemodynamic and postoperative outcome. Such a technique should be part of the surgical armamentarum.