Re-evaluation of the criteria for asymmetric amplatzer occluders in the closure of perimembranous ventricular septal defects: A case series report.

Rationale: To discuss suitable criteria for the application of asymmetric Amplatzer occluders for perimembranous ventricular septal defects (pmVSDs). Patients concerns and diagnoses: We retrospectively studied 18 children with perimembranous VSDs who underwent attempted asymmetric occluder closure between January 2015 and December 2018 in our center. Interventions: Asymmetric Amplatzer occluders were attempted to be placed to all the enrolled patients. We analyzed the diameter of the defects with the receiver operating characteristic curve (ROC) values, the size of the occluders attempted, the presence of aneurysm and the presence of aortic valve prolapse for each patient. Then, for patients who experienced successful device implantation, the therapeutic efficiency was evaluated by follow-up. Outcomes: Only 5 out of a total of 18 patients completed successful device implantation. Compared with failed cases, successful cases demonstrated a significantly smaller VSD size (5.46 +/- 1.03 mm vs. 8.73 +/- 2.33 mm,P = 0.012) and had a low ratio of aortic valvar prolapse (20% vs. 76.92%,P = 0.026). Four out of 5 successful cases involved arrhythmia complications, but the rhythm of the heart recovered after drug treatment. According to the ROC and Youden analyses, the cut-off value of the defect size for successful asymmetric Amplatzer occluder implantation was no larger than 5.7 mm. Lessons: The application of an asymmetric Amplatzer occluder expands the range of indications for patients with superior localized VSD but is largely limited in cases with aortic valvar prolapse and large VSD sizes. All successful cases recovered from arrhythmia postprocedure.