Based on the size of the defect, perimembranous VSDs between 4-18 mm in diameter would be suitable for closure with the Amplatzer VSD occluder. The device size would need to be selected based on the actual defect size as assessed by echocardiography. Adequate rims around the defect are required but specifics on rim measurements are not provided in this document. Other factors such as indications for closure and no contraindications to the percutaneous approach would also need to be evaluated for a particular patient.

1. VSD DEVICE CLOSURE

2.  Most common congenital heart disease in both
adults and children
 Prevalence: 20% in isolation. 30-50% with
associated defects

3.  Etiology: Congenital or Acquired
 Location: Inlet, Outlet, Trabecular,
Perimembranous
 Size: Small, Moderate, Large

4.  Traditionally surgical closure
 Lock et al:
 1988
 6 patients
 Congenital/Acquired VSD
 Rashkind double umbrella device
 A-V wire loop technique

5. Carminati et al
 12 papers until 2006
 Success rate: 87-100%
 Major complicaions: 0-15%
 Need for PPI: 0-8%

6. Carminati et al
 European VSD registry
 430 patients , ITT, 23 referral hospitals
 119 muscular, 250 membranous, 16 multiple,
45 post op
 Multiple devices
 Overall success rate: 95.3%

7.  Early complication: 12.7%
 Significant complication: 6.5%
 Death: 0.2%
 Device embolosation: 0.9%
 Tachyarrhytmia:0.7%
 Early CHB: 2.8%. 6 during procedure, 6 within
one week, all in PM VSD

8. Butera et al
 104 patients, PM VSD, Single centre
 CHB in 9 patients , PPI in 6 patients
 Multivariate analysis: Age a risf factor for CHB
with a RR of 0.25
 Only noted in children less than 6 years of age

9. Holtzer et al
 Large International registry of PM VSD using
Amplatzer device
 100 patients
 Procedural success: 93%
 Immediate complete closure:58.1% with <2mm
shunt in 95.7%

10.  Adverse events in 29.5% with arrhytmia MC
with 13%, new or increased AR in 9.2%, new
or increased TR in 9.2%

11. Chinese series
 2079 patients, mostly PM VSD
 Amplatzer or Chinese Symmetric/Asymmetric
devices
 Procedural success: 98.6%
 Residual shunt >2mm in 0-4.7%
 Adverse events in 2.5-19.3%, CHB in 0.1-
7.6%, PPI in 0.2%

12. Study Bass et
al
Thanopou
los et al
Pedra et
al
Miro et al Fu et al
Year 2003 2003 2004 2005 2006
No. of
patients
27 10 10 54 35
Age in yrs 1.25 - 32 1.5 - 12 6 - 32 0.5 - 61 1.2 - 54.4
Weight 8.5-80 kg 11-49 kg 19-80 kg 6-77 kg 8-110 kg
Qp:Qs 1.6 1.93±0.29 1.5-5.5(2) 1.7±0.6 (1.8)
Device
size (mm)
4-12 4-8 8-18 6-18 6-16
Successful
implant
93% 100% 100% 94% 91%

13. Study Bass et al Thanopou
los et al
Pedra et
al
Miro et al Fu et al
Residual
shunt
2/27 0/10 1/10 9/54 1/35
CHB 0 0 0 3+2 (10%) 1
AR 2 0 0 1 12%
LBBB/RB
BB
1 3 LBBB 1 NR NR
Hemolysis 0 0 0 2 2
Others 1 0 LVOTO-2 0 2

14. Study European
Registry
Butera et
al
Predsecu
et al
Year 2007 2007 2008
No. of
patients
430 104 20
Age in yrs 8 (0.4 to
70 years)
14 (0.6-63
years)
1.6 (0.5 –
16.2
years)
Weight in
kg
28 (4-124
kg)
26.5 (6.5
– 96 kg)
9.7 (6.2-
43 kg)
Qp:Qs 2.1 (1-8) 2 (1.3-5)
Device
size (mm)
7 (3-22) 8 (4-16)
Successful
implant
410/435
(95%)
100/104
(96.2%)
20/20
(100%)
Game Changers

15. Study European
Registry
Butera et
al
Predsecu
et al
Residual
shunt
NA 1/104 0/20
CHB 16/430
(3.7%)
6/104
(5.7%)
4/20
(20%)
AR 14 (2) 0 0
LBBB/RB
BB
10 3 0
Hemolysis 5 (1.2% 0 0
Others NA 3

16.  Skeptics went up in arms
 Damning the device and the procedure
 Many radicals suffered
 Most conservatives survived
 What almost killed the procedure
“Overenthusiasm”

17. Introspection
 Patient selection
 Problems with AAPMVSDO
 Short waist 2 mm
 Stiff discs
 High “clamp force”
 Device selection
 PFM Le coils
 ADO I
 ADO II
 Modified devices

19. Qin et al (Am J Cardiol
2008; 101:1781-86)
Yang et al (Eur Heart J
2010; 31:2238-45)
Period of Study 2002-2005 2002-2008
Total no of cases 412 848
Age 16.4 ± 9.1 years 9 (2-73 years)
Gender (M:F) 202 : 210 426 : 406
Weight 30.5 (10-88)
Basic Data

20. Devices Used
Qin et al (Am J Cardiol
2008; 101:1781-86)
Yang et al (Eur Heart J 2010;
31:2238-45)
AAPMVSDO 0 103
Symmetric/Assymmetric
MVSDO (SSMA)
398 729
Success
Qin et al (Am J Cardiol
2008; 101:1781-86)
Yang et al (Eur Heart J 2010;
31:2238-45)
398/412 (96.6%) 832/848 (98.2%)

21. Complications
Qin et al (Am J Cardiol
2008; 101:1781-86)
Yang et al (Eur Heart J
2010; 31:2238-45)
Device Embolization 3 (2 retrieved and
redeployed)
2 (Surgical removal)
NeoAR 3 (device removed) 1 (Requiring Sx)
NeoTR 1 (Device removed) 1 (Requiring Sx)
Residual shunt 0 405
LBBB
RBBB
Junctional rhythm
10
16
6
15
32
CHB 6 (Recovered in 3 weeks, No
PPI)
5 (2 requiring PPI)
7 not
requirin
g Sx

22. Thakker et al Nageshwar Rao
et al ( CCVI
2011; 77:252-
59), (JACC 2012;
60:2421-22)
Jayrangnath et
al
Dalvi et al
(CCVI 2006;
68:145-52),
(CCVI 2006;
68:620-28)
Period of
Study
2007-2012 2006-2012 2010-2012 2000-2012
Total no of
cases
431 158 158 102
Age 1 year to 38
years (7.6
years)
6m to 22 years
(4.6 years)
9m to 41 years
(5.3years)
11m to 21 years
(4.2 years)
Gender (M:F) 255:176 71:87 91:67 68:34
Weight 8.2 – 72 (20) 6.2 – 55 (14) 7.5 – 64 (21) 7.7 - 56 (16)
Basic Data

23. VSD types
Thakker et
al
Nageshwar Rao
et al
Jayrangnath et
al
Dalvi et al
Perimembrano
us
310 108 136 76
Muscular 83(34) 38(4) 18(0) 22(3)
Postop
(Residual)
2 8 4 1
Others 2
(Subpulmoni
c)
0 0 0

24. Approach
Thakker et al Nageshwar Rao
et al
Jayrangnath et
al
Dalvi et al
Transvenous 397 64 112 85
Transarterial 0 94 46 14
Hybrid 34 4 0 3
Success 423/431
(98.1%)
150/158 (95%) 157/158
(99.3%)
100/102 (98%)

25. Devices Used
Thakker et al Nageshwar Rao
et al
Jayrangnath et
al
Dalvi et al
AAPMVSDO 1 19 12 61
Symmetric
VSDO
113(SSM) +
159 (Starway)
11 (Lifetech) 0 0
MVSDO 32 20 8 15
ADO I 88 18 90 11
ADO II 0 87 46 14
ASO 1 0 2 0

26. Complications
Thakker et al Nageshwar Rao
et al
Jayrangnath et
al
Dalvi et al
Device
Embolization
4 3 1 1
NeoAR 4 (1) 3 1 6
NeoTR 3 2 5 12 (1)
Acute MR 0 1 (1) 0 0
Hypotension 0 2 0 1
CHB 5 0 1 0

27. ECG Changes
Thakker et al Nageshwar Rao
et al
Jayrangnath et
al
Dalvi et al
Isorrhythmic
AVD
7 0 2 1
RBBB 6 9 2 6
LBBB 2 0 0 1
IRBBB 0 0 0 3
LAHB 1 0 0 3

28. Follow up
Thakker et al Nageshwar Rao
et al
Jayrangnath et
al
Dalvi et al
Duration 1-54 months 1-56 months 1-30 months 1-134 months
Late onset
CHB
0 0 0 0
Device
migration
0 0 0 0
Thromboemb
olism
0 0 0 0
Pericardial
effusion
0 0 0 0
Residual
Shunt
13 10 2 3

29. Follow up
Thakker et al Nageshwar Rao
et al
Jayrangnath et
al
Dalvi et al
Duration 1-54 months 1-56 months 1-30 months 1-134 months
Late onset
CHB
0 0 0 0
Device
migration
0 0 0 0
Thromboemb
olism
0 0 0 0
Pericardial
effusion
0 0 0 0
Residual
Shunt
13 10 2 3

30. Post infarct VSD
 Grave prognosis
 Mortality:
 Medical: 90%(30 days) 97%(1 year)
 Surgery: 47%(30 days) 53%(1 year)
 Device favourable to surgery

31. Holtzer et al
 US registry of Amplatzer PI VSD
 18 patients, 5 acute, 13 subacute
 Success: 89%
 Mortality: 25 % (30 days)
 20% moderately large shunt on follow up

32. Thielle et al
 Amplatzer device in acute MI VSD
 29 patients, cardiogenic shock in 55%
 Success: 86%
 Mortality:
 Overall: 35% (30 days)
 CS: 88%
 Non CS: 35%

33. Which VSD is suitable for device
closure?
 Look at:
Indication for closure
Location of defect
Size of defect
Rims to neighboring structures
Contraindications for percutaneous
closure

34. Which VSD is suitable for device
closure?
 Look at:
Indication for closure
Location of defect
Size of defect
Rims to neighboring structures
Contraindications for percutaneous
closure

35. dications for VSD Closure
 Relevant shunt:
 Qp/Qs > 2 : 1 and LV volume overload
 Qp/Qs > 1.5 : 1* and
 PA pressure < 2/3 of systemic pressure and
PVR < 2/3 of systemic Vascular resistance
 Qp/Qs > 1.5 : 1 and
 LV systolic or diastolic failure
 History of endocarditis
*CCS Guidelines 2006, AHA Guidelines 2008 /ESC 2012

36. Indications for VSD closure
Signs for small VSD
 Asymptomatic
 Echo:
 High velocity jet through VSD
 No LV volume overload
 No pulmonary hypertension
 Catheterization:
 Qp:Qs < 1.5
 Mean pulmonary artery pressure < 25 mmHg
 Low PVR < 200 dyn.s.cm-5
 Many VSDs are small and do not require

37. Indications for VSD closure
LV overload
Z-score of LVEDD > +2

38. Indications for VSD closure
Doppler gradients across the VSD to estimate RV pressure

39. Indications for VSD Closure
RV pressure? Reversible PHT?

40. INDICATIONS FOR VSD
CLOSURE
QP:QS
Qp/Qs can be estimated by using 2D echo
and spectral Doppler measurements

41. Which VSD is suitable for device
closure
 Look at:
Indication for closure?
Location of defect
Size of defect
Rims to neighboring structures
Contraindications for percutaneous
closure?

42. Which VSD is suitable for device closure?
Location

43. Echocardiographic delineation of pmVSD
Perimembraneous VSD
Supracristal
(=doubly committed/subpulmonary/conal/
infundibular/outlet/subarterial) VSD
Membraneous/
Perimembraneous
VSD
Lynch P

45. Subpulmonary
= supracristal
inlet
Echocardiographic delineation of various VSDs
Not suitable for
Device closure
based
on location
assessed
by echo

46. Which VSD is suitable for device
closure
 Look at:
Indication for closure?
Location of defect
Size of defect (suitable device
available?)
Rims to neighboring structures
Contraindications for percutaneous
closure?

47. • Clamshell, Cardioseal-/
Cardioseal-Starflex
– ~ 300 patients
J Lock, Boston
VSD-Closure Devices

48. Amplatzer Closure Devices
• ASD (4-36 mm)
• Post-MI VSD (16-24 mm)
• Perimembraneous VSD
• VSD (4-18 mm)

49. Which VSD is suitable for device closure
Suitable device for defect? rims?
• Diameters 4 – 18 mm central
waist (1 mm increments)
• Waist: same size or 1 mm >
defect
• Rim between defect/aortic
valve ≥ 2mm
Amplatzer pmVSD
PFM VSD coil •Effective defect diameter ≤ 8mm
•No aortic rim required
•Aneurysm preferable

50. Which VSD is suitable for device closure
Suitable device for defect? rims?
• Waist diameters: 4-18 mm
(2 mm increments)
• Waist: 7 mm; Discs:
Waist + 8 mm
(surrounding rim ≥ 4mm)
• Waist should be 1-3 mm
larger than the largest
diameter of the VSD
Amplatzer muscular VSD occluder

51. Which VSD is suitable for device closure
Suitable device for defect? rims?
 Not suitable based on
echocardiographic assessment:
Defect diameter too large (no
appropriate device available)
Rims too small or even absent (e.g. rim
to aortic valve)

52. Which VSD is suitable for device
closure
 Look at:
Indication for closure?
Location of defect
Size of defect (Suitable device
available?)
Rims to neighboring structures
Contraindications for percutaneous
closure?

53. Exclusion criteria for
percutanous VSD closure
 Overriding aorta (malalignment VSD)
 Supracristal/ inlet VSD
 Associated significant aortic regurgitation
 Prolapse of aortic cusp
 Sub-aortic stenosis
 Sub-pulmonary stenosis
 Eisenmenger syndrome

54. Exclusion criteria for VSD closure
Overriding Aorta (TOF) Aortic cusp prolapse
(= malalignment VSD)
prolapse of aortic cusp

55. Exclusion criteria for VSD closure
Supracristal VSD Inlet VSD

56. Take home message
Suitability for VSD closure
Suitable for Device closure
 Adequate indication for
closure
 Location:
perimembraneous/
muscular
 Diameter suitable for
device closure
 Adequate rims to
neighboring structures
(device dependent)
 No contraindication for
VSD closure
Not suitable for device closure
 No indication for closure
 Location: supracristal /
inlet
 Diameter too large for
device closure
 Missing/absent rims to
neighboring structures
(device dependent)
 Contraindications for
VSD closure present
(e.g. AV prolapse ± AR(
malalignment VSD)
Decision for suitability of VSD closure can be made by echo!

57. Perimembranous VSD

58. 

59. Device selection
 Type of the device
 Size of the device

60. Determinants of the Device type
 Size of the defect
 Morphology of the defect

61. Size of the defect
 ADO II : upto 5.5 mm
 Nit Occlud Le VSD coil : upto 8 mm
 ADO I : upto 12 mm
 AAPMVSDO & AMVSD occluder : upto 16 mm
 Modified Membranous VSD occluders
(Lifetech and Shanghai Steel Corp) : upto 19
mm

62. Morphology of the defect
 Presence of TV aneurysm
 Separation of the defect from the AoV
 Presence of aortic valve prolapse
 Extension into the inlet

63. Presence of TV aneurysm
 Mandatory for ADO I and Nit Occlud coil
 Absence of aneurysm : Need a double disc
design (Symmetrical or asymetrical)

64. • Presence of aneurysm
• PFM coil
• ADO I

66. Distance from the aortic valve
 < 3 mm : AAPMVSDO and Nit Occlud
 > 3 mm : ADO I, ADO II, AMVSDO, Symmetric
devices

67. • Small defect (5 mm)
• > 3mm separation from the Ao Valve
• ADO II 6 X 4

68. • Moderate sized defect (7 mm)
• > 3mm separation from the Ao Valve
• ADO I 10 X 8

69. • Moderate sized defect (8 mm)
• < 3mm separation from the Ao Valve

70. Presence of Ao Valve prolapse
 Severity of prolapse
 Presence and severity of AR

71. Extension into the inlet
 Use a device with a minimum clamp force
 Coil (Nit Occlud) or a single disc design (ADO
I)
 Devices with wider waist (ADO II, AMVSDO,
Modified devices)

72. Sizing the device
 No definite guidelines
 Echo Vs Angio
 LV Vs RV
 APMVSDO: RV side of the defect. Measure in
two planes. Average and add 1
 ADO I: RV side of the defect + 1 or 2 =
Pulmonary end of the ADO I
 ADO II: RV side of the defect + 0.5 to 1 mm

73. Muscular VSD

74. Devices used


75. Type of device
 Size of the defect
 Morphology of the defect

76. Size of the defect
 ADO II: upto 5.5 mm
 Nit Occlud: upto 8 mm
 ADO I: Upto 12 mm
 AMVSDO: Upto 16 mm

77. Morphology of the defect
 Simple : Point of entry and exit are opposite
each other – Any of the devices
 Complex : Coursing within the IVS – ADO II or
Nit Occlud

82. AMPLATZER Membranous VSD Occluder
 Self-expandable Nitinol mesh with polyester patches
 Non-concentric design to avoid interference with the aortic valve
 Sizes: 4 -18mm
Device Size (Waist = A)
Right Ventricular Disc (B)
Left Ventricular Disc (C)
Device Size
(Waist = A)
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
RV Disc (B) 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
LV Disc (C) 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Legend

83. Strengths
 Specifically designed for PMVSDs
 Asymmetric design is ideal for preventing
aortic valve injury
 Separation from the aortic valve – 2mm
 Upto 8 kg
 VSD size of upto 16 mm

84. Choosing the device size
 No definite rule
 Echocardiographic Vs angiographic
 LV diameter Vs RV diameter
 1-2 mm > than the measured diameter

88. Limitations
 Protrusion into the LVOT
 Interference with aortic and tricuspid valve
mechanisms
 CHB

89. Biggest concern
COMPLETE HEART BLOCK
 0 – 5%
 Smaller children (< 8 kg)
 Large defects
 Inlet extension
 Associated Down’s syndrome

90. Study Bass et
al
Thanopou
los et al
Pedra et
al
Miro et al Fu et al
Year 2003 2003 2004 2005 2006
No. of
patients
27 10 10 54 35
Age in yrs 1.25 - 32 1.5 - 12 6 - 32 0.5 - 61 1.2 - 54.4
Weight 8.5-80 kg 11-49 kg 19-80 kg 6-77 kg 8-110 kg
Qp:Qs 1.6 1.93±0.29 1.5-5.5(2) 1.7±0.6 (1.8)
Device
size (mm)
4-12 4-8 8-18 6-18 6-16
Successful
implant
93% 100% 100% 94% 91%

91. Study Bass et al Thanopou
los et al
Pedra et
al
Miro et al Fu et al
Residual
shunt
8% 0% 10% 17% 4%
CHB 0 0 0 3+2 1
AR 2 0 0 1 12%
LBBB/RB
BB
1 3 TLBBB 1 NR NR
Hemolysis 0 0 0 2 2
Others 1 0 LVOTO-2 0 2

92. AMPLATZER Membranous VSD Occluder 2
Conforms to the Ventricular Anatomy
 The concave left ventricular (LV) disc is shaped to
conform with the septal wall
 The compliant outer waist allows the device to
conform to the shape of the defect
Minimizes Pressure on the Septal Tissue1
 The 3 mm waist length reduces clamp force on the
ventricular septum
Promotes Closure and Stability
 Polyester-filled waist and discs promote closure of
the defect
 Concave, oval-shaped LV disc promote stability

93. AMPLATZER® Membranous VSD Occluder 2
Device Sizes
18 available sizes:
 9 waist diameters: 4-10,12,14mm
 2 rims: 1mm & 3mm
 All sizes have a 3 mm waist length
Rim
Waist Diameter
Waist Length

94. 94
ADO I
Model /
Reorder
Number
[A] Device Diameter
at Descending Aorta
(mm)
[B] Device
Diameter at
Pulmonary Artery
(mm)
[C]
Retentio
n Skirt
(mm)
[D]
Length
(mm)
Recommended
Sheath Size (with
AMPLATZER TorqVue
Delivery System)
9-PDA-
003
5 4 9 5 5 F, 180° Curve
9-PDA-
004
6 4 10 7 6 F, 180° Curve
9-PDA-
005
8 6 12 7 6 F, 180° Curve
9-PDA-
006
10 8 16 8 6 F, 180° Curve
9-PDA-
007
12 10 18 8 7 F, 180° Curve
9-PDA-
008
14 12 20 8 7 F, 180° Curve
9-PDA-
009
16 14 22 8 7 F, 180° Curve

95. ADO I - Strengths
 Smaller access
 CHB has not been reported
 Less expensive

96. Choosing the size
 Echo Vs Angiographic
 Minimum diameter on the RV aspect + 2mm
should be the size of the pulmonary end

97. Limitations
 Was not designed for PMVSD
 Only those with a good TV aneurysm
 Separation from the aortic valve – 4-5 mm
 PMVSD upto 12 mm at the RV end
 Aortic retention disc encroaching on the AV
 Interference with the TV mechanism
 Severe PHT

100. ADO II Specifications
Model /
Reorder
Number
[A] Waist
Diameter
(mm)
[B] Device
Length
(mm)
[C] Disc
Diameter
(mm)
Recommended Catheter Size (with
AMPLATZER TorqVue LP Delivery
System)
9-PDA2-03-04 3 4 9 4 F
9-PDA2-03-06 3 6 9 4 F
9-PDA2-04-04 4 4 10 4 F
9-PDA2-04-06 4 6 10 4 F
9-PDA2-05-04 5 4 11 5 F
9-PDA2-05-06 5 6 11 5 F
9-PDA2-06-04 6 4 12 5 F
9-PDA2-06-06 6 6 12 5 F
.
A C
B

101. ADO II - Advantages
 Softer (No polyester patch)
 Wider waist
 CHB has not been reported
 Ease of deployment (Arterial side)

102. Limitations
 Not designed for PMVSD: length is an issue
 Separation from the aortic valve – 4 mm
 Modifications in the delivery system
 Close VSDs only upto 5 to 5.5 mm
 Encroachment on the aortic valve and LVOT
 Impairment of TV mechanism

104. Nit-Occlud Le VSD coil
 Coil design with attached polyester fibres
 Outstanding adaptation properties
 Broad range of different sizes (8 – 16 mm
distal diameter)
 Small delivery system (6 to 7 Fr)
 No CHB reported – High flexibility

105. Device Selection
 Distal diameter (D) at least twice the minimal
diameter of the VSD on the right ventricular
side and 1–2 mm greater than, the diameter of
the VSD at the LV side.
 P = proximal, D = distal

106. Limitations
 PMVSD < 8 mm at the RV end
 Aneurysm formation is mandatory
 Absence of PHT

107. Courtsey: Trong Phi Li, MD

108. AMPLATZER Muscular VSD
Occluder
108
 Self-expandable Nitinol mesh with polyester patches
conform to the ventricular septum
 Waist length: 7mm
 Sizes: 4-18mm
Device Size (Waist = A)
Right Ventricular Disc (B)
Left Ventricular Disc (C)
Length of Waist (D)
Legend
Device Size (Waist = A) 4 6 8 10 12 14 16 18
RV Disc (B) 9 14 16 18 20 22 24 26
LV Disc (C) 9 14 16 18 20 22 24 26
Length of Waist (D) 7 7 7 7 7 7 7 7

109. Advantages
 Waist is broad
 Used upto 16-17 mm
 Even in those with PHT

110. Disadvantages
 Not designed for PMVSD closure
 Larger sheath
 Encroachment on the LVOT and aortic valve
 TV mechanism

111. Exclusion
 Small children
 Large VSDs
 Significant aortic valve prolapse
 More than mild AR
 Down’s syndrome
 Severe PHT

113. Follow-up after VSD closure-
what to look for?

114. Major complications
 Complete AV block
 • Aortic-/ Tricuspid valve dysfunction
 • Malposition/embolization of device
 • Residual defect (severe)
 • Severe hemolysis
 Carminati M et al.European H J 2007, 28:
2361
 Kenny D et al: Catheter Cardiovasc Interv
2009, 73:568-75

115. Minor complications
 Transient arrythmias
 • Residual defect (small)
 • Transient hemolysis
 • Inguinal hematoma and fistula
 Carminati M et al.European H J 2007, 28:
2361
 Kenny D et al: Catheter Cardiovasc Interv
2009, 73:568-75

116. Major early and late
complications →
mainly complete AV
block!

117. Relationship between VSD and
conduction system
The conduction tissue is primarily placed postero-inferiorly with reference to
membraneous VSDs, while it is placed antero-superiorly in most of the muscular VSDs
Lynch PJ. C Carl Jaffe Yale University

118.  The day after the procedure:
 • ECG
 • TTE
 • Chest X-ray
 Discharged on:
 • ASS 100 mg/die
 • Prophylaxis against infective endocarditis
(IE)

119.  1, 6, 12, 24 months, then every 2nd year
 •Symptoms?
 –dizziness, syncope, dyspnea, hemolytic
anemia ...
 •Murmurs?
 • ECG- abnormalities?
 •TTE (TEE if required):
 Residual defect? Tricuspid valve dysfuntion?
 AR? RVOT/LVOT obstruction?Device
malposition?
 Development of discrete subaortic