Transcatheter closure of multi-hole perimembranous ventricular septal defect with aneurysm using two occluders

A 33-year-old man presented to our department for recurrent respiratory tract infections since early childhood. His physical and mental development was normal. A grade 4/6 pansystolic murmur was heard over the left sternal border.
Transthoracic echocardiography (TTE) revealed a moderate-sized perimembranous ventricular septal defect (PmVSD) with a 14 mm × 9 mm aneurysm (Figures 1 A, B). The diameter of the exit was 5 mm. The left atrium and ventricle were dilated. Their diameters were 35 mm and 55 mm respectively. There were mild mitral and tricuspid regurgitations. We attempted to perform a transcatheter closure of this PmVSD under general anesthesia with the guidance of fluoroscopy and echocardiography.
However, a left ventricle (LV) angiogram showed that the VSD was characterized by two exits with diameters of 7 mm and 5 mm basipetally (Figure 2 A). The entrance diameter was 18 mm. The lower VSD, measuring 5 mm, was located near the crest of the interventricular septum, and the upper VSD, measuring 7 mm, was located close (2.5 mm) to the aortic end of the septal aneurysm. The distance between the two exits was 4.5 mm.
A 7 mm and a 6 mm modified double-disk symmetrical ventricular occluder (lifetech Ltd, Shenzhen, China), similar to the Amplatzer occluder, were used in this procedure. First, the upper exit was crossed from the arterial side using a 6-Fr Launcher Judkins Right 3.5 (JR3.5) guiding catheter with the use of a Terumo wire (Terumo Inc., Japan). The Terumo wire was then exchanged for a 260 cm long noodle wire (AGA Medical, Golden Valley, MN, USA). Then an arterial-venous wire loop was established from the right femoral artery to the right femoral vein via the defect as previously described. Over the wire a Lifetech delivery sheath was introduced from the femoral vein through the VSD to the LV. Under the guidance of fluoroscopy and TTE, a 7 mm double-disk symmetrical ventricular occluder was deployed across the defect. The first disc was deployed on the left ventricular side of the septum, and the catheter was pulled back to another disc on the right ventricular side of the defect. Repeated angiogram was then obtained (Figure 2 B).
The lower exit then was crossed using the same guiding catheter and wire from the left femoral artery to the left femoral vein. A 6 mm double-disc symmetrical occluder was deployed across the lower defect overlapping with the first device using the same technique, with excellent results...


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