Intraoperative device closure of perimembranous ventricular septal defects without cardiopulmonary bypass: Preliminary results with the perventricular technique

Objective: In infants undergoing closure of perimembranous ventricular septal defects, cardiopulmonary bypass remains one of the factors that prolongs hospital stay and morbidity. A new technique was used to close the defects under echocardiographic guidance without cardiopulmonary bypass to prevent the deleterious effects of bypass. Methods: Recently, the Amplatzer membranous ventricular septal defect device (AGA Medical Corp, Golden Valley, Minn) was introduced. The device has a double-disc design with a short connecting waist. The left ventricular disc has an eccentric design to prevent encroachment on the aortic valve leaflets. Eight Yucatan miniature pigs with naturally occurring perimembranous ventricular septal defects underwent closure of the defect in the operating room by using the perventricular technique. After median sternotomy, a purse-string suture was placed on the free wall of the right ventricle. An angiocatheter was advanced in the right ventricle, and through the catheter, a wire was advanced from the right ventricle through the ventricular septal defect into the left ventricle. A delivery sheath and the dilator were advanced over the wire. The wire and catheter were removed, and appropriately sized Amplatzer membranous device was advanced through the sheath. The device was deployed under echocardiographic guidance with the heart beating. Results: The procedure was successful in all animals. There was no incidence of device embolization, heart block, or aortic insufficiency. Angiograms at 3 and 6 months revealed no residual defects and no aortic insufficiency. Pathologically, the devices were completely endothelialized when examined grossly. Conclusions: The perventricular technique appears to be excellent for closure of perimembranous ventricular septal defects in the operating room. The technique might be feasible in smaller babies, who are high-risk candidates for closure in the catheterization laboratory. Cardiopulmonary bypass and prolonged hospital stay are avoided.