Simultaneous Transcatheter Closure of Ventricular Septal Defect and Pulmonary Valvuloplasty
A 12-year old boy presented with history of exertional dyspnea and atypical chest pain. Physical findings were suggestive of severe valvar pulmonic stenosis. Electrocardiogram showed right axis deviation with right ventricular hypertrophy. Chest X Ray revealed normal sized heart with hypovascularity of lung fields. Echocardiography revealed medium sized perimembranous VSD and severe pulmonary stenosis with a peak systolic gradient of 85 mmHg across the pulmonary valve.\nAt cardiac catheterization, the right ventricular pressure was systemic (RV pressure = 115 mmHg) and the gradient across the pulmonary valve was 91 mmHg. There was a trivial net left to right shunt with calculated QP/QS of only 1.1. Right ventricular angiogram showed right ventricular hypertrophy with evidence of severe pulmonary stenosis. Main pulmonary artery, left and right pulmonary branches were dilated. A medium to large sized perimembranous VSD was appreciated by both right and left ventricular angiogram. Since both anomalies appeared amenable to percutaneous treatment, concurrent transcatheter therapy was planned after taking a written informed consent from the parents. The patient was started on heparin (100 IU/Kg) after obtaining venous and arterial access. The procedure was performed under local anesthesia and moderate sedation with pethidine and promethazine.\nA decision was taken to close the VSD first, followed by dilation of pulmonary valve. The procedure was tried with Amplatzer VSD occluder No. 10 mm and 12 mm and could not be closed due to large defect size. Therefore devices were retrieved. Then a 14 mm Amplatzer VSD occluder was implanted across the VSD and its position verified by left ventriculography and transthoracic echocardiography (, ).\nAfter VSD closure, there was no change in RV pressure and transpulmonic systolic pressure gradient. Therefore we decided to perform balloon pulmonary valvuloplasty.\nPulmonary valvuloplasty was performed with 25 mm pulmonary balloon catheter (25×40 mm, TYSHAK II, NUMED Canada inc.) (pulmonary valve annulus measured 23) (, ). Immediately after balloon pulmonary valvuloplasty, right ventricular systolic pressure decreased from 115 to 45 mmHg, which resulted in a decrease in transvalvular gradient to 22 mmHg.\nEchocardiography 24 h after procedure showed mild residual Ps (PG = 25mmHg) and no residual shunt. Follow up echocardiography at 1, 6 and 12 months showed mild residual Ps (PG = 20 mmHg) and no residual shunt.