BACKGROUND: Percutaneous closure of perimembranous ventricular septal defects (VSD) has been performed with the new Amplatzer membranous septal occluder. We report further experience with this device.

METHODS: In 12/03, 10 patients (median age and weight: 14 years and 34.5 kgs, respectively) underwent percutaneous VSD closure under general anesthesia and transesophageal guidance (TEE). The VSD diameter was 7.1 ± 4.0 mm by angiography and 7.8 ± 3.7 mm by TEE (R=0.92). Three patients had a true aneurysm of the membranous septum (2 with multiple exit holes), 4 had defects shrouded by lots of adjacent tricuspid valve tissue, 2 had subaortic defects with no tricuspid valve involvement and one had a right aortic cusp prolapse with mild aortic regurgitation. The VSD was crossed in a retrograde fashion and an arterial-venous guide wire loop was established after snaring maneuvers. A 7-9 Fr braided sheath was advanced from the femoral vein to the left ventricle. A device 1-2 mm larger than the defect (mean diameter: 10.2 ± 3.9 mm) was loaded, advanced through the sheath and implanted in a standard way.

RESULTS: Implantation was successful in all patients, however in 2 patients the initial device had to be changed for a larger one. Kinkings in the delivery sheath, inability to position the sheath near the left ventricular apex and device prolapse through the VSD prompted modifications in the standard technique of implantation. Device orientation was excellent, except in one case. Fluoroscopic and procedure time were 39 ± 15 and 129 ± 42 minutes, respectively. Occlusion rate was 7/10 after 24 hrs and 9/10 within 1-3 months, with a tiny (1 mm) residual shunt in one patient. Device-related tricuspid insufficiency, arrhythmias, and embolization were not observed. Aortic regurgitation jet width increased from 10 to 15% in the patient with cusp prolapse. Two patients had slight gradients across the left ventricular outflow tract 24 hrs after implantation, normalizing after 3 months.

CONCLUSIONS: In this initial experience, the Amplatzer membranous septal occluder was suitable to close a wide range of perimembranous VSD sizes and morphologies with excellent short-term outcomes. Longer follow-up is required.

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