Pediatric Cardiology

, Volume 36, Issue 7, pp 1386–1392 | Cite as

Transcatheter Closure of Perimembranous Ventricular Septal Defects with Left Ventricular to Right Atrial Shunt

  • Gunter KerstEmail author
  • Axel Moysich
  • Siew Yen Ho
  • Christian Apitz
  • Heiner Latus
  • Dietmar Schranz
Original Article


During the development of so-called aneurysmal transformation of perimembranous ventricular septal defects (pmVSD), tricuspid valve (TV) morphology and function may be altered resulting in left ventricular (LV) to right atrial (RA) shunting. The feasibility and outcome of interventional closure of these pmVSD has not been investigated so far. Interventional closure of pmVSD associated with mild to moderate LV-to-RA shunt was performed in four patients (aged 6.5–12.5 years). pmVSD were closed under fluoroscopic guidance by establishing an arteriovenous wire loop via a femoral artery and advancing the delivery sheath from a femoral vein. Before device release (or withdrawal if necessary), residual shunting across the device and TV valve function was investigated by transthoracic echocardiography and LV angiography. pmVSD sizes of 4, 5.5, 8 and 8.5 mm were closed with a 4/4 and 6/6 Amplatzer duct occluder II and an 8- and 10-mm Amplatzer muscular VSD occluder device, respectively. There were no or only minor residual postinterventional LV-to-RA shunts. No atrioventricular blocks were observed during a mean follow-up of 12.5 months (range 6.5–17 months). Transthoracic echocardiography indicated that the elimination of the VSD jet pushing the antero-superior TV leaflet open is the key mechanism for LV-to-RA shunt reduction after transcatheter pmVSD closure. Interventional closure in pmVSD associated with mild to moderate indirect LV-to-RA shunting is feasible and results in significant reduction in or elimination of LV-to-RA shunting.


Congenital heart disease Perimembranous ventricular septal defect Gerbode defect Interventional cardiology 


Conflict of interest


Supplementary material

Video 1, 2. Tricuspid valve morphology and function before (1) and after (2) VSD closure by a 4/4 ADO II (patient #2), evaluated by transthoracic echocardiography (modified parasternal short axis view) with simultaneous color Doppler interrogation. (mp4 codec). Supplementary material 1 (MP4 1992 kb)

Supplementary material 2 (MP4 2283 kb)


  1. 1.
    Anderson RH, Lenox CC, Zuberbuhler JR (1983) Mechanisms of closure of perimembranous ventricular septal defect. Am J Cardiol 52:341–345CrossRefPubMedGoogle Scholar
  2. 2.
    Bouchardy J, Therrien J, Pilote L, Ionescu-Ittu R, Martucci G, Bottega N et al (2009) Atrial arrhythmias in adults with congenital heart disease. Circulation 120:1679–1686CrossRefPubMedGoogle Scholar
  3. 3.
    Butera G, Carminati M, Chessa M, Piazza L, Micheletti A, Negura DG et al (2007) Transcatheter closure of perimembranous ventricular septal defects: early and long-term results. J Am Coll Cardiol 50:1189–1195CrossRefPubMedGoogle Scholar
  4. 4.
    Freedom RM, White RD, Pieroni DR, Varghese PJ, Krovetz LJ, Rowe RD (1974) The natural history of the so-called aneurysm of the membranous ventricular septum in childhood. Circulation 49:375–384CrossRefPubMedGoogle Scholar
  5. 5.
    Gerbode F, Hultgren H, Melrose D, Osborn J (1958) Syndrome of left ventricular-right atrial shunt; successful surgical repair of defect in five cases, with observation of bradycardia on closure. Ann Surg 148:433–446PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Hagler DJ, Squarcia U, Cabalka AK, Connolly HM, O’Leary PW (2002) Mechanism of tricuspid regurgitation in paramembranous ventricular septal defect. J Am Soc Echocardiogr 15:364–368CrossRefPubMedGoogle Scholar
  7. 7.
    Hijazi ZM (2003) Device closure of ventricular septal defects. Catheter Cardiovasc Interv 60:107–114CrossRefPubMedGoogle Scholar
  8. 8.
    Ho SY, McCarthy KP, Rigby ML (2004) Morphology of perimembranous ventricular septal defects: implications for transcatheter device closure. J Interv Cardiol 17:99–108CrossRefPubMedGoogle Scholar
  9. 9.
    Holzer R, de Giovanni J, Walsh KP, Tometzki A, Goh T, Hakim F et al (2006) Transcatheter closure of perimembranous ventricular septal defects using the Amplatzer membranous VSD occluder: immediate and midterm results of an international registry. Catheter Cardiovasc Interv 68:620–628CrossRefPubMedGoogle Scholar
  10. 10.
    Jacobs JP, Burke RP, Quintessenza JA, Mavroudis C (2000) Congenital heart surgery nomenclature and database project: ventricular septal defect. Ann Thorac Surg 69:S25–S35CrossRefPubMedGoogle Scholar
  11. 11.
    Leung MP, Mok CK, Lo RN, Lau KC (1986) An echocardiographic study of perimembranous ventricular septal defect with left ventricular to right atrial shunting. Br Heart J 55:45–52PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Michel-Behnke I, Le TP, Waldecker B, Akintuerk H, Valeske K, Schranz D (2005) Percutaneous closure of congenital and acquired ventricular septal defects—considerations on selection of the occlusion device. J Interv Cardiol 18:89–99CrossRefPubMedGoogle Scholar
  13. 13.
    Pedra CA, Pedra SR, Esteves CA, Pontes SC Jr, Braga SL, Arrieta SR et al (2004) Percutaneous closure of perimembranous ventricular septal defects with the Amplatzer device: technical and morphological considerations. Catheter Cardiovasc Interv 61:403–410CrossRefPubMedGoogle Scholar
  14. 14.
    Qin Y, Chen J, Zhao X, Liao D, Mu R, Wang S et al (2008) Transcatheter closure of perimembranous ventricular septal defect using a modified double-disk occluder. Am J Cardiol 101:1781–1786CrossRefPubMedGoogle Scholar
  15. 15.
    Ramaciotti C, Keren A, Silverman NH (1986) Importance of (perimembranous) ventricular septal aneurysm in the natural history of isolated perimembranous ventricular septal defect. Am J Cardiol 57:268–272CrossRefPubMedGoogle Scholar
  16. 16.
    Schwedler G, Lindinger A, Lange PE, Sax U, Olchvary J, Peters B et al (2011) Frequency and spectrum of congenital heart defects among live births in Germany : a study of the competence network for congenital heart defects. Clin Res Cardiol 100:1111–1117CrossRefPubMedGoogle Scholar
  17. 17.
    Sutherland GR, Godman MJ, Smallhorn JF, Guiterras P, Anderson RH, Hunter S (1982) Ventricular septal defects. Two dimensional echocardiographic and morphological correlations. Br Heart J 47:316–328PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Tucker EM, Pyles LA, Bass JL, Moller JH (2007) Permanent pacemaker for atrioventricular conduction block after operative repair of perimembranous ventricular septal defect. J Am Coll Cardiol 50:1196–1200CrossRefPubMedGoogle Scholar
  19. 19.
    Tzikas A, Ibrahim R, Velasco-Sanchez D, Freixa X, Alburquenque M, Khairy P et al (2014) Transcatheter closure of perimembranous ventricular septal defect with the Amplatzer® membranous VSD occluder 2: initial world experience and one-year follow-up. Catheter Cardiovasc Interv 83:571–580CrossRefPubMedGoogle Scholar
  20. 20.
    Vijayalakshmi IB, Narasimhan C, Singh B, Manjunath CN (2013) Treatment of congenital non-ductal shunt lesions with the amplatzer duct occluder II. Catheter Cardiovasc Interv. doi: 10.1002/ccd.25250 PubMedGoogle Scholar
  21. 21.
    Wu MH, Chang CI, Wang JK, Lue HC (1994) Characterization of aneurysmal transformation in perimembranous ventricular septal defects: an adhered anterior leaflet of tricuspid valve predisposes to the development of left ventricular-to-right atrial shunt. Int J Cardiol 47:117–125CrossRefPubMedGoogle Scholar
  22. 22.
    Wu MH, Wang JK, Lin MT, Wu ET, Lu FL, Chiu SN et al (2006) Ventricular septal defect with secondary left ventricular-to-right atrial shunt is associated with a higher risk for infective endocarditis and a lower late chance of closure. Pediatrics 117:e262–e267CrossRefPubMedGoogle Scholar
  23. 23.
    Wu MH, Wu JM, Chang CI, Wang JK, Wu YN, Chien SC et al (1993) Implication of aneurysmal transformation in isolated perimembranous ventricular septal defect. Am J Cardiol 72:596–601CrossRefPubMedGoogle Scholar
  24. 24.
    Yang J, Yang L, Yu S, Liu J, Zuo J, Chen W et al (2014) Transcatheter versus surgical closure of perimembranous ventricular septal defects in children: a randomized controlled trial. J Am Coll Cardiol 63:1159–1168CrossRefPubMedGoogle Scholar
  25. 25.
    Yang R, Kong XQ, Sheng YH, Zhou L, Xu D, Yong YH et al (2012) Risk factors and outcomes of post-procedure heart blocks after transcatheter device closure of perimembranous ventricular septal defect. JACC Cardiovasc interv 5:422–427CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Gunter Kerst
    • 1
    Email author
  • Axel Moysich
    • 1
  • Siew Yen Ho
    • 2
  • Christian Apitz
    • 1
  • Heiner Latus
    • 1
  • Dietmar Schranz
    • 1
  1. 1.Department of Pediatric Cardiology, Pediatric Heart Center GiessenUniversity Children’s HospitalGiessenGermany
  2. 2.Cardiac Morphology Unit, Royal Brompton HospitalImperial College LondonLondonUK

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