OCCLUSION OF CONGENITAL VENTRICULAR SEPTAL-DEFECTS BY THE BUTTONED DEVICE

Objectives-To study the feasibility of congenital ventricular septal d efect occlusion by the buttoned device and to establish guidelines for its safe and effective application. Design-A descriptive study of all patients with a congenital ventricular septal defect undergoing trans catheter occlusion with the buttoned device, from March 1994 to May 19 95. These patients were otherwise candidates for elective surgery at t heir institutions because they had persistence of a significant shunt (Qp:Qs = 1.5-2.1:1, median = 1.7), with left ventricular enlargement a nd/or symptoms, although their systolic pulmonary artery pressure was invariably normal (20-28 mm Hg, median = 25). The angiographic diamete r of the defect ranged from 2.5 to 14 mm (median 6 mm). Setting-A mult i-institutional study. Patients-Out of 25 cases attempted, 18 children and adults aged 4-35 years had devices implanted. Fifteen of these pa tients had membranous ventricular septal defects and three had muscula r defects. All patients with a membranous ventricular septal defect ha d an associated aneurysm of the membranous septum. Interventions-The b uttoned device was introduced either directly or, in the last 12 cases , over a wire bridging the femoral artery and the femoral or jugular v ein; the devices were delivered through 7-9 French (F) long sheaths. A membranous defect was regarded as suitable for device closure if the distance from the centre of the defect to the insertion of the right c oronary aortic valve leaflet was more than 50% of the size of the requ ired device. The device was guided by echocardiography and fluoroscopy . All muscular defects were corrected through the right jugular vein a nd all membranous ones through the femoral vein. Results-All 18 patien ts underwent initial successful implantation of the device. In thirtee n patients the shunts were completely occluded and in the remaining fi ve there were trivial residual shunts. In two patients with membranous ventricular septal defects a change from the original position was no ticed at two weeks; mild aortic regurgitation developed in one and the murmur recurred in the other; the devices had to be removed surgicall y. One patient developed transient third degree atrioventricular block during implantation; no tricuspid regurgitation was observed. Conclus ion-Clinical occlusion of congenital ventricular septal defects was ac hieved in 16 out of the 18 attempted cases (13 full occlusions). Membr anous ventricular septal defect occlusion can be effective and safe if patients and device sizes are carefully selected.