Transesophagography Identifies Guide Wire Impingement on the Tricuspid Valve Chordae Duringtranscatheter Closure of the Perimembranous Ventricular Septal Defect

Abstract

Percutaneous transcatheter device closure of the perimembranous ventricular septal defect (VSD) in proper case is now an alternative to surgical VSD repair. However, some complications during the transcatheter closure procedure might happen, which includean impingement of the arteriovenous rail (AVr) in the chordae of tricuspid valve (TV) and result in chordae rupture withsevere tricuspid regurgitation. Conventionally, we used fluoroscopic images to help judginga ‘safe, straightAVr’ from a ‘wrong, curvedAVr’.Determined to observe the right from wrong AVr course with transesophagography (TEE) directly, we performed this study. This retrospective study enrolled 17 patients of perimembranous VSD that received transcatheter VSD closing procedure in Children's Hospital of China Medical University, Taichung, Taiwan in last 4 years. Philips iE33 Echocardiography with omniplane TEE probes were used. TEE study kept going on throughout the whole procedure. The spatial relationships between guiding wire, AVr, delivery long sheath and the AO valve, VSD, aneurysm tissue and TV were particularly noticed of. TV leaflets restriction or deformity by the guide wire or AVr, with or without tricuspid regurgitation, were considered as signs of chordae impingement and the AVr must be removed and re-attempted. Guide wire impingement on TV chordae occurred in one patient and AVr impingement occurred in 4 patients. Compared to the conventional fluoroscopic guideline of ‘wrong, curved AVr line’, only 2 of the 4 AVr impingement cases displayed this fluoroscopic curved line. Instead, TEE observed quite a few significant image abnormalities of TV restriction, including ‘dome-shape deformity of the septal leaflet at systole’, ‘ring-shape deformity at diastole’, ‘seagull deformity of TV at systole’, ‘hanging bed-deformity of TV at diastole’, and ‘redundant tissue tag’ etc., in addition to the appearance of TV regurgitation. For ascertain a safe AVr course that was passing rightly through the membranous VSD and the TV commissure, the fluoroscopic imageaddress only roughly ‘a straight’ from ‘a curved’ AVr line. TEE appeared to be a superior and useful modality for a detail description of TV impingement by AVr or guide wire.