Transcatheter VSD Closure in patient with Aortic Valve Prolapse (AVP)

The aim of this study is evaluation of efficacy transcatheter VSD closure in patients with Sub AO VSD, small insufficient Sub Ao rim, significant AVP and present of up to mild AI. 35 patients with subaortic VSDs combined with AVP, up to mild AI underwent transcatheter closure of VSDs. Subjects had indications for transcatheter closure of PM VSD associated AVP and trivial to mild AI were verified by TTE. The patients ranged in age from 3 years to 15 years and in weight from 1O kg to 65 kg. The mean VSD diameter was 5 mm, with a range of 3 mm to 12 mm. The mean pulmonary to systemic flow ratio (Qp/Qs) was 1.6:1, with a range of 1.4:1 to 2.2:1. Inclusion criteria of patients was subaortic VSDs combined with AVP, up to mild AI is confirmed by TTE. The development of AVP is a risk factor for increasing AI was also confirmed. Rhythm disturbances were reported more frequently, with Transient complete heart block in 2 patients, device-related mild to moderate TR occurred in 5 cases.The main reason for it was contributed to that the diameter of defects and a limited aortic rim could present a significant challenge to operator. If the left ventricular disc of occluder impairs leaflets of aortic valve, will have a significant AI. There were no severe complications related to the procedure. On the other hand, we also founded that two patients with transient complete AVB, may be occurred cause of oversized VSD occluder transiently compress adjacent conduction tissues and induce the local edema. Our follow-up demonstrates other encouraging results with no progressive AI, also we believe that direct closure actually improved degree of AVP and secondary AI. Base on general agreement of that prolapse of the aortic valve leaflet were the dominant factor of AI, the potential mechanism may be occluders support and change original hemodynamic configuration like Venturi effect is created by the left-to-right shunting through the VSD during systole, the edge of device offer a commissural support from subaortic zone to prolapsed aortic valve leaflet and prevent progressive AI.DiscussionThere are rare reports in the literature provide clinical information on device closure of VSDs in patients with AVP and mild AI. The presented cases are showing challenging anatomical situations which may be encountered when performing percutaneous closure of VSD. Despite significant anatomical restriction, procedures could be safely and effectively performed. The present study shows an excellent outcome with a very high rate of success closure and a low incidence of complications.