Transcatheter Closure of Ventricular Septal Defect Using Detachable Cook Coil

Introduction:

Interventional cardiac catheterization procedure has proved a significant advance in the non-operative treatment of many congenital heart defects. Transcatheter device placement has been successfully used for closure of patent ductus arteriosus (PDA), Atrial Septal Defects (ASD), Blalock Taussig shunt, Aorto-pulmonary window (A-P window) and recently for ventricular septal defects11. Closure of VSD by using detachable coil is a very rare option which was performed on 3 dogs in Japan in 2004 which showed minimal residual shunt12. Coil embolization of PM VSD of another dog was performed in Tokyo University Japan in 200513. Human experience of a closure of VSD with the detachable coil is very limited. We report transcatheter closure of a perimembranous VSD using a detachable Cook Coil.

Case Report

A 4-years-old boy had the history of failure to thrive and recurrent respiratory tract infections in early infancy. He had pneumonia at the age of 3 months and VSD was diagnosed incidentally at that time. He was managed conservatively since than with Digoxin and frusemide. Recently he had been complaining of easy fatigue and excessive sweating after exercise. His routine investigations like chest radiography and ECG were normal. Transthoracic colour Doppler echocardiography showed a 3 mm perimembranous VSD with a septal aneurysm and it was 5 mm away from the aortic valve. He also had partial anomalous drainage of left pulmonary veins to left superior vena cava. Left SVC (LSVC) in tern was draining to left atrium with a flow of blood towards superior vena cava and right atrium. Unroofed coronary sinus was noticed. He had a history of bacterial endocarditis 6 months ago. As anomalous systemic and pulmonary venous connections had no haemodynamic impacts, closure of PM VSD with a detachable coil was planned. The patient was taken into the catheterization laboratory on 31 December 2008. He was sedated with injection Ketamine. Left ventriculography confirmed the size of VSD and distance from the aortic valve. Right heart catheterization confirmed the presence of left SVC opening to LA and anomalous connection of left pulmonary veins to left SVC. The VSD was crossed initially with the help of 0.35 Terumo wire and 4 French Judkin’s right (JR) coronary catheter.

Catheter and wire was forwarded to right atrium. Than Terumo wire was exchanged with a 260 cm hydrophilic J tip wire. JR catheter was exchanged with a Torcon catheter. Catheter tip was placed below the tricuspid valve. Another Multipurpose (MPA) Another catheter was placed in left atrium to left ventricle through left SVC for giving contrast injection to visualize VSD. A 5 mm x 4 loop cook coil was connected to delivery cable and was introduced to Torcon catheter and forwarded to RV. Two loops were released on RV side and the catheter was pulled back slowly to LV side and rest two loops were released inside aneurysmal tissue. Contrast injection from LA showed complete occlusion of shunt. Aortic valve was checked by careful colour flow mapping for the presence of any aortic regurgitation. ECG was observed carefully for any evidence of complete heart block. The delivery cable was than unscrewed and coil was released carefully. Injection Heparin was not given to the patient during procedure. ECG and Echo on next morning was satisfactory. Patient was discharged 3 days after procedure.

Discussion

The earliest interventional procedure to be applied in the catheterization laboratory was balloon atrial
septostomy11. Shortly thereafter nonsurgical closure of patent ductus arteriosus and Atrial Septal Defect
was acheived12,13. Non surgical closure of VSD is much less well accepted and can only be regarded
as an option for very limited cases and available only in few centers worldwide14. Transcatheter closure has
been attempted in selected cases of VSD by using lock clamshell device, Rashkind umbrella device,
sideris buttoned devices and lastly by Amplatzer devices.

Occlusion of VSD by coil was first reported in 1982. But that case was intended from Rashkind double umbrella closure. Failing to do that inspired the cardiologists to close VSD with a detachable coil of 8 x 4 mm size. That procedure was done through femoral venous approach. In the present case, the coil was deployed retrograde and the coil was delivered first to RV side through a Torcon catheter. Other than perimembranous VSD this case also had persistent left SVC opened to left Atrium and unroofed coronary sinus with drainage of left pulmonary veins to PLSVC. These anomalous venous connections has no significant haemodynamic impacts, so left untouched. For LV angiography, MPA catheter was introduce through PLSVC to LA to LV during coil deployment. This is the first reported case of VSD closure with a cook detachable coil through retrograde approach in a patient with nonsignificant anomalous systemic and pulmonary venous connection. In conclusion, VSD coil occlusion through retrograde approach is a safe and effective procedure in perimembranous VSD cases covered with aneurysm tissue.