Page 33 - Journal of Structural Heart Disease Volume 5, Issue 5

New Technology
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Table 2: Procedural details of Trans-aortic retrograde VSD closure using ADO I like device.
Case no
Occluder size, mm
Delivery system, Fr
Residual shunt
Fluoroscopy time, min.
Procedure time, min.
1
2
3
4
5
6
7
8 Median SD
6/8 7
6/8 7 10/12 8 10/12 8
8/10 7 4/6 7 10/12 8 6/8 7
No 15.6 No 15.7 No 13.2
Minimal 14.4 No 11.1 No 12.2 No 13.4 No 10.6
25.6 27.2 25.0 24.7 19.4 18.2 22.3 18.6
mm: millimeter; Fr: French size; min: Minutes; SD: Standard Deviation
Discussion
To the best of our knowledge, this is the first re- ported case series in literature using a combination of retrograde VSD device closure technique and ADO I like device. Though the retrograde approach has been described before using the ADO II device [1–3], there are some limitations in cases with aortic rim less than 5 mm and more procedure time and radiation expo- sure. The ADO II device is also relatively expensive to use in resource limited contexts such as the Indian setting. Koneti et al. reported the fluoroscopy time of 14 minutes in their series where trans-arterial ret- rograde technique was done using an ADO II device. [4] In our series, fluroscopy time was 13.3 minutes. As our experience grew, there was further reduction of fluroscopy time from 15.7 to 10.6 minutes.
In this series, we used an ADO I like device - ‘Co- coon Device” [manufactured by Vascular lnnvova- tions Co. Ltd. Nonthaburi, Thailand & marketed by Vascular Concepts, Bangalore, India] for the first time using a trans-aortic retrograde technique. We were able to use this device in all cases irrespective of aor- tic rim size. Another advantage of using ADO I like device is that it has a low profile with small retention disc on the right ventricular side and no disc on the left ventricular side which lowers the risk of encroach- ment on vital cardiac structures. We also used 7/8 Fr
13.3 23.5 13.275 22.722
PDA delivery systems, which helped in achieving bet- ter stability for delivery of device without any twist or kink across the interventricular septum. Koneti et al., on the other hand, used the right coronary guide catheter for the delivery of retrograde devices. They encountered tortuosity of the catheter while across the septum which was overcome by using an extra support coronary guide wire (buddy wire) [1].
Porstmann et al. did the first trans-catheter closure of Patent Ductus Arteriosus (PDA) in 1967. Later, Lock et al. reported transcatheter closure of VSD using ‘Rashkind double umbrella’ device in 1988 [5]. After the introduction of the Amplatzer device in 1999, the closure of muscular VSDs using the Amplatzer mus- cular VSD occluder (MVSDO) was published in 2002. Though transcatheter closure of muscular VSDs, was a better option than surgical closure, significant in- cidence of atrioventricular block varying from to 3-20% was seen [6]. Despite the development of the dedicated Amplatzer Perimembranous VSD Occluder (PMVSDO) for the closure of perimembranous VSDs, a occurrence of AVB was a concern [7, 8]. The tranve- nous antegrade technique had more radiation expo- sure and cumbersome procedure. The trans-arterial retrograde technique, initially using the Amplatzer symmetrical muscular VSD device [9, 10] and sub- sequently the ADO II device to minimize the risk of atrioventricular block (AVB) and tricuspid valve en-
Journal of Structural Heart Disease, October 2019
Volume 5, Issue 5:221-228