PRIMARY TRANSCATHETER UMBRELLA CLOSURE OF PERIMEMBRANOUS VENTRICULAR SEPTAL-DEFECT

Objectives-The starting hypothesis was that some perimembranous ventri cular septal defects can be closed safely and effectively with a Bard Rashkind double umbrella introduced through a long transvenous sheath. Design-A descriptive study of all patients who underwent attempted tr anscatheter umbrella closure of a perimembranous ventricular septal de fect, Those patients selected for the study had symptoms of a ventricu lar septal defect and a perimembranous ventricular septal defect shown by transthoracic echocardiography. The morphological criteria used we re a posterior perimembranous defect with a diameter of less than or e qual to 8 mm not associated with overriding of the aortic or pulmonary valve or with aortic valve prolapse. The haemodynamic criteria for in clusion in the study were a right to left ventricular systolic pressur e ratio of > 0.45, a Doppler derived right ventricular systolic pressu re of > 50 mm Hg, and a pulmonary to systemic flow ratio > 3:1. Settin g-A tertiary referral centre. Patients-13 infants, children, and adole scents with a perimembranous ventricular septal defect aged 3 weeks to 16 years and weighing 1.8-46 kg. Interventions-A modified Rashkind du ctal double umbrella was introduced through a long transvenous sheath and positioned on either side of the ventricular septal defect. Placem ent was guided by transoesophageal echocardiography. Results-10 out of 13 patients underwent successful partial or complete closure of a per imembranous ventricular septal defect. There were three placement fail ures. Two of these were associated with a ventricular septal defect to o large for the umbrella device. In a third case the umbrella was open ed in the left ventricular outflow tract necessitating surgical remova l and closure of the ventricular septal defect. Conclusion-Trans cathe ter umbrella closure of a perimembranous ventricular septal defect is technically feasible and can be therapeutically successful, although t he procedure is moderately difficult to perform and the mean procedure time is > 120 minutes. It is an alternative to surgery in some cases, but the overall results would not support its routine use even with t he introduction of larger devices of the current design.