VSD

Ventricular Septal Defect

(We have performed this procedure maybe twice at CPMC. Please update as steps and equipment evolve.)

Anesthesia	Imaging	Access	Notes
General	Fluoro TEE	Either RIJ or RVF RFA	Acist setup 100 % for LV gram

Spies/Daniels

Equipment

• Micropuncture
• (2) 6F pinnacle sheaths (maybe)
• 6F balloon wedge
• JR4 Diagnostic
• JR4 Guide with Touhy and stopcock
• .035 x 150 J wire
• .035 x 260 J Wire
• Angled 260 Glidewire
• .035 torquer
• 60cc syringe
• 25mm Gooseneck snare
• TorqueVue 45 Degree (Don't open, 9 and 10F on standby)
• Amplatzer Post Infarct Muscular VSD Occluder (Bottom shelf of plug cart. Largest size we have is a 22, Mills has a 24 if case is pre-planned.)
• 6F Straight Pigtail
• Perclose
• Fluoro cover(s) for anesthesia's IV pole and if in hybrid for the boom

Procedural Steps

• Access is dependent upon location of VSD. Will always have one venous and one arterial access.
• Pigtail advanced and LV gram performed to visualize the VSD. Pigtail exchanged over 360J wire for the JR4 Diagnostic.
• On the venous side the balloon wedge is floated to the PA. Balloon wedge removed over 260J and JR4 Guide advanced to the PA, 260J wire removed and gooseneck advanced thru the guide.
• On the arterial side, the 260 angled glide wire is advanced thru the JR4 diagnostic. Glide wire utilized to cross the defect and wire advanced to the PA.
• Glide wire snared by gooseneck and externalized on the venous side (will need two Kelly's to clamp both ends of the wire).
• JR4 Guide removed, along with the venous sheath and the TorqueVue is advanced over the glide wire to "kiss" the JR4 Diagnostic catheter at the defect. Glide wire is removed once "kiss" is in the right position and occluder is advanced thru the TorqueVue.
• LV disk deployed in the LV and occluder pulled to septum for RV disk deployment. (This part is tricky and may require repeated attempts. Each time occluder is removed you will need to repeat initial steps of advancing balloon wedge, exchanging for the JR4Guide with snare, re-wiring the defect and snaring the glide.)

Notes: If patient has a RIJ PA catheter, catheter will be pulled and sheath prepped for procedural access. Swan will be re-floated at end of case.