Iatrogenic perimembranous ventricular septal defect is a rare complication after surgical
replacement of the aortic valve, and so transcatheter closure of such a defect is not a routine
procedure. We report the successful closure of an iatrogenic perimembranous ventricular
septal defect which occurred after the replacement of the aortic valve and ascending aorta. 
(Cardiol J 2008; 15: 189-191

Anisimowicz, Lech

Chojnicki, Maciej

Pawliszak, Wojciech

Sukiennik, Adam

Świątkiewicz, Iwona

English

Via Medica Journals

CASE REPORTCardiology Journal2008, Vol. 15, No. 2, pp. 189–191Copyright © 2008 Via MedicaISSN 1897–5593www.cardiologyjournal.org 189Address for correspondence: Maciej Chojnicki, MD, PhD, Department of Cardiology and Internal Diseases,Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, M. Skłodowskiej-Curie 9, 85–094 Bydgoszcz, Poland,tel: +48 52 585 40 23; fax: +48 52 585 40 24, e-mail: maciej.chojnicki@cm.umk.plReceived: 12.11.2007 Accepted: 19.02.2008Transcatheter closure of iatrogenic perimembranousventricular septal defect after aortic valve andascending aorta replacement using anAmplatzer membranous ventricular septal occluderMaciej Chojnicki1, Adam Sukiennik1, Lech Anisimowicz2,Iwona Świątkiewicz1 and Wojciech Pawliszak21Department of Cardiology and Internal Diseases, Nicolaus Copernicus University,Collegium Medicum, Bydgoszcz, Poland2Department of Cardiac Surgery, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, PolandAbstractIatrogenic perimembranous ventricular septal defect is a rare complication after surgicalreplacement of the aortic valve, and so transcatheter closure of such a defect is not a routineprocedure.  We report the successful closure of an iatrogenic perimembranous ventricularseptal defect which occurred after the replacement of the aortic valve and ascending aorta.(Cardiol J 2008; 15: 189–191)Key words: interventional treatment, postsurgical ventricular septal defect,aortic valve replacementIntroductionIatrogenic perimembranous ventricular septaldefect is a rare complication after surgical replace-ment of the aortic valve. Small defects are usuallyhemodynamically insignificant and do not need tobe closed. However, some of the small ventricularseptal defects occurring after such surgery maygradually enlarge, and subsequent intervention maybe indicated. Since 2002, when Hijazi et al. [1] pu-blished their initial experience of percutaneous clo-sure of congenital perimembranous ventricular sep-tal defect with an Amplatzer membranous ventri-cular septal defect  occluder, this procedure hasbeen considered an alternative to surgical closurein several centres [2–4]. However, transcatheterclosure of iatrogenic perimembranous ventricularseptal defect after aortic valve replacement was firstdescribed by Holzer et al. [5] in 2004 and is notroutine procedure.We report the successful closure of an iatroge-nic perimembranous ventricular septal defect(PMVSD) which occurred after previous replace-ment of the aortic valve, and subsequent replacementof the ascending aorta and valve with composite graft.Case reportA 70-year-old male with a history of aortic va-lve replacement with St Jude prosthesis performedthree years previously was admitted with type-Aacute ascending aortic dissection. Urgent replace-ment of the aortic valve and dissected ascendingaorta was performed. In view of the age of thepatient and the heavily damaged tissues in the aor-tic ring, a modified composite graft made of a Da-cron tube with incorporated Hancock II valve bio-prosthesis was used, similar to the technique descri-bed by Urbanski [6]. The post-operative course wascomplicated by a complete heart block, which needed190Cardiology Journal 2008, Vol. 15, No. 2www.cardiologyjournal.orgimplantation of a pacemaker, and prolonged mecha-nical ventilation due to chronic obstructive pulmo-nary disease. Transthoracic and subsequent trans-oesophageal echocardiography revealed a restricti-ve 6 mm PMVSD. Because of the lack of symptoms(New York Heart Association functional class II) andthe shunt estimated as hemodynamically insignifi-cant, the patient was managed conservatively andsent home. However, six months later the patientshowed deterioration of exercise capacity to NewYork Heart Association functional class III/IV. Echo-cardiography revealed that the ventricular septaldefect had increased in size from 6 mm to 10 mm.Because of his general condition and previous sur-gical history, percutaneous closure of the perimem-branous ventricular septal defect was recommendedto avoid the risk of yet another surgical intervention.The procedure was performed with a standardtechnique using fluoroscopic and transoesophage-al echocardiographic guidance [1].Right femoral vein and right femoral arteryapproach was used. The aortic bioprosthesis wascrossed using a 6 F, 3.5 cm Judkins right coronarycatheter over a 0.035” Terumo glide wire (Teru-mo). A 6 F pigtail catheter was advanced over a wireto the left ventricle. Left ventriculography demon-strated a 10 mm perimembranous ventricular sep-tal defect (Fig. 1). Consequently, the pigtail cathe-ter was exchanged for a 6 F, 3.5 cm Judkins rightcoronary catheter. The tip of catheter was manipu-lated to the PMVSD, and the glide wire was advan-ced to the right ventricle and the main pulmonaryartery. The Judkins catheter was advanced to themain pulmonary artery and the glide wire wasexchanged for a 0.035”, 300 cm long Noodle wire(AGA Medical). The wire was snared from the mainpulmonary artery using a 25 mm Gooseneck snare(Microvena) and exteriorized out the right femoralvein. Over the wire from the venous side, an 8 FTorqueview delivery sheath (AGA Medical) wasadvanced. During attempts to pass the deliverysheath through the ventricular septal defect, theventricular pacing lead was dislodged, so a tempo-rary pacing lead was placed in the right ventricle.The ventricular septal defect was closed using thetechnique described in detail by Hijazi et al. [1].A 12 mm Amplatzer perimembranous ventricularseptal defect occluder was used. Angiography afterimplantation of the device revealed a trivial leakthrough the mesh of the device (Fig. 2). The pro-cedure was otherwise uncomplicated and at the enda new permanent pacing electrode was implanted.Echocardiography a day after the procedure showedcomplete closure of the ventricular septal defect.Follow-up assessments six months and one yearafter the procedure confirmed complete closure ofthe ventricular septal defect, no aortic bioprosthe-sis dysfunction and improvement of symptoms toNew York Heart Association functional class II.Figure 1. Cineangiographic image in the long-axial obliqueview demonstrating the ventricular septal defect (blue ar-row) and position of aortic bioprosthesis (white arrow).Figure 2. Cineangiographic image in the long-axial obli-que view after implantation of a device in the ventricu-lar septal defect demonstrating a trivial leak throughthe centre of the device (white arrow), position of aorticbioprosthesis (white star) and displacement of ventri-cular pacing electrode (blue arrow).191Maciej Chojnicki et al., Transcatheter perimembranous ventricular septal defect closurewww.cardiologyjournal.orgDiscussionPercutaneous closure of ventricular septal de-fects is an alternative to the surgical treatment in se-lected cases. Ventricular septal defects are a rare com-plication after cardiac surgery but they may occurmore often in patients who have undergone repeatcardiac surgery in the left ventricular outflow tract.In such patients, further repeat surgery may carry anincreased operative risk. Therefore, percutaneoustreatment with a device is an attractive therapeuticoption. Results of transcatheter closure of iatrogenicventricular septal defect, even in patients with me-chanical aortic valve prosthesis, have been publishedin the past few years and are very encouraging. Hol-zer et al. [5] first described two patients with iatroge-nic perimembranous ventricular septal defect afteraortic valve replacement, who were treated by trans-catheter interventional device closure. Our patientunderwent an operation in which a dissection of theascending aorta and previously implanted mechani-cal aortic valve prosthesis were removed and repla-ced with a composite graft using a biological valvesewn into a Dacron tube using Urbanski’s method.The prosthetic valve in this type of operation is sewninto the aortic graft, a few millimetres above the le-vel of the native aortic orifice (Fig. 3). Urbanski’s me-thod allows the use of a prosthetic valve of at least onesize bigger than conventional conduits and carries theadvantage of easily obtaining a tight, elastic and hemo-static composite graft connection to the left ventricle.In our case, the distance between the proximal aorticvalvular edge and the upper border of the ventricularseptal defect allowed percutaneous closure of the ia-trogenic defect using a device. Special care must betaken when crossing the aortic bioprosthesis to avoiddamage to the prosthesis leaflet.Iatrogenic ventricular septal defect is a rare butpotentially serious complication of aortic valve re-placement and may be difficult to treat. Interven-tional closure of a hemodynamically significant pe-rimembranous ventricular septal defect with anAmplatzer PMVSD occluder (AGA Medical) is po-ssible in patients in whom a ventricular septal de-fect is likely to occur after previous replacement ofthe ascending aorta and valve.AcknowledgmentsThe authors would like to thank ProfessorMichael Tynan and doctor Shakeel Qureshi for re-view of the manuscript. We would also like to thankTomasz Rozwadowski for preparation of the figures.The authors do not report any conflict of inte-rest regarding this work.References1. Hijazi Z, Hakim F, Haweleh A et al. Catheter closure of per-imembranous ventricular septal defect using the new Amplatzermembranous VSD occluder: Initial experience. Catheter Cardio-vasc Interv, 2002; 56: 508–515.2. Masura J, Gao W, Gavora P et al. Percutaneous closure of per-imembranous ventricular septal defects with the eccentric Am-platzer device: Multicenter follow-up study. Pediatr Cardiol,2005; 26: 216–219.3. Szkutnik M, Qureshi S, Kusa J, Rosenthal E, Bialkowski J. Useof the Amplatzer muscular ventricular septal defect occluder forclosure of perimembranous ventricular septal defects. Heart,2007; 93: 284–286.4. Walsh M, Coleman D, Oslizlok P, Walsh K. Percutaneous clo-sure of postoperative ventricular septal defects with the Am-platzer device. Catheter Cardiovasc Interv, 2006; 67: 445–451.5. Holzer R, Latson L, Hijazi Z. Device closure of iatrogenic mem-branous ventricular septal defects after prosthetic aortic valvereplacement using the Amplatzer membranous ventricular sep-tal occluder. Catheter Cardiovasc Interv, 2004; 62: 276–280.6. Urbanski P. Replacement of ascending aorta and aortic valvewith a valve stentless composite graft. Ann Thorac Surg, 1999;67: 1501–1502.Figure 3. Schematic demonstration of the position ofventricular septal defect (blue arrow) and bioprosthesis(black arrow). Note the intermittent line shows previousprosthetic valve position.

Transcatheter closure of iatrogenic perimembranous ventricular septal defect after aortic valve and ascending aorta replacement using an Amplatzer membranous ventricular septal occluder

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Transcatheter closure of iatrogenic perimembranous ventricular septal defect after aortic valve and ascending aorta replacement using an Amplatzer membranous ventricular septal occluder

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