Patient has been diagnosed with perimembranous VSD since childhood, recently experienced progressive dyspnea for a year with NYHA Class II, and paroxysmal nocturnal dyspnea, indicative of heart failure. Improvement with diuretics was observed. Surgical VSD correction was turned-down due to severe pectus excavatum. As a result, the patient was referred to our facility for transcatheter VSD closure, given concerns about surgical risks related to the pectus excavatum.

Laboratory tests were unremarkable. ECG showed no abnormalities. Chest X-ray revealed cardiomegaly and pectus excavatum. TTE and TEE demonstrated normal ventricular function (LVEF 66%), a dilated left ventricle (LVIDd 5.4 cm), an 11x5 mm perimembranous VSD causing a left-to-right shunt, and an intact interatrial septum. No endocarditis was detected, and all four pulmonary veins drained into the left atrium, with no significant valvular stenosis or regurgitation.

Right heart catheterization revealed the absence of an evident oxygen step-up and the absence of pulmonary hypertension (mean pulmonary arterial pressure: 19 mmHg).Additionally, it confirmed the presence of a significant left-to-right shunt with a pulmonary-to-systemic flow ratio (Qp:Qs) of 2.2. The left ventriculogram also demonstrated an 8.2 mm ventricular septal defect with a left-to-right shunt.

-The patient underwent a procedure under general anesthesia.-6F sheaths were placed into the right radial artery and the right femoral artery, with a 7F sheath introduced into the right femoral vein.-Right heart catheterization was conducted, revealing the absence of pulmonary hypertension (MPAP 18 mmHg).-A left ventriculogram demonstrated the presence of a ventricular septal defect (VSD) with a left-to-right shunt.-A 6F JR 4.0 catheter, guided by a 0.035" guidewire under the supervision of TEE and fluoroscopic guidance, was advanced from the LV to RV and subsequently positioned within the pulmonary artery.-A 20 mm snare was introduced through the right femoral vein via an MP catheter into the pulmonary artery. The guidewire, which had initially been passed from the aorta to the pulmonary artery, was retrieved using the snare and externalized through the right femoral vein to create an arteriovenous loop.-Subsequently, the MP catheter and the 6F sheath at the right femoral vein were removed, and a 9F SteerEase introducer sheath was inserted, crossing the VSD into the aorta.-A Konar-MF VSD occluder (14-12 mm) was deployed in antegrade fashion with fluoroscopy and TEE guidance via the 9F sheath delivery system.-Post-procedure left ventriculograms confirmed the accurate positioning of the occlusion device, without any significant shunt.-TEE confirmed well-seated VSD closure device, with minimal flow observed across the device and no interference with aortic and tricuspid valves.

This patient required VSD closure due to LV volume load without pulmonary hypertension. While surgical closure typically yields low operative mortality and favorable long-term results, the presence of pectus excavatum and resultant restrictive lung disease posed a high operative risk. Therefore, we opted for an alternative method: transcatheter closure. Despite the inherent risks like complete AV block, TR, and AR associated with transcatheter VSD closure, the procedure was completed without any complications in this case.