Objective. To report our experience with perventricular closure of apical muscular ventricular septal defects (VSD) in small infants when transcatheter closure is impractical and no hybrid suite or X-ray guidance is available.
Methods and Results. Since 2006, 6 infants with large muscular VSDs underwent perventricular closure under transesophageal echocardiography and/or epicardial echocardiography guidance, at a median age and weight of 4.5(0.3-16.9) months and 4.7(2.5-7.8) kg, respectively. A single Amplatzer device with a median size of 12 (4-14) mm was deployed in each patient, 1-2mm larger than the VSD measured on echocardiography. Two patients had multiple VSDs. One had a significant residual shunt and pulmonary hypertension despite successful deployment of a 12mm device. He underwent successful surgical repair through right ventriculotomy. The second patient was a neonate weighting 2.5 kg with a complex aortic arch obstruction, multiple VSDs and a small left ventricle. Perventricular closure was associated with aortic arch repair and closure of a membranous VSD, under cardiopulmonary bypass. Because of residual shunting through a third apical VSD, pulmonary artery banding was attempted but the patient died from an irreversible cardiac arrest intraoperatively. The 4 other patients had successful VSD closure with no/minimal residual shunt. One had associated right ventricular pseudoaneurism resection and pulmonary artery banding removal, under cardiopulmonary bypass.
Conclusion. Perventricular closure is feasible under echocardiographic guidance only in small patients with single VSD. Cases with multiple VSDs seem more complicated and may beneficiate from additional X-Ray guidance.