Use of the Amplatzer Vascular Plug II for Occlusion of the Native Right Ventricular Outflow Tract in Single Ventricle Palliation

Background: Pulsatile antegrade flow in the pulmonary circulation in patients with a bidirectional cavopulmonary connection (BCPC) has been suggested to improve long term outcome, but may cause volume loading and prolonged pleural drainage, necessitating occlusion of the residual connection between the ventricle and the pulmonary artery.

Objectives and Methods: To describe the utility of the Amplatzer Vascular Plug II in closing a residual ventriculopulmonary connection after BCPC and provide a review of the available literature on device closure of such connections in single ventricle patients.

Results: We used an Amplatzer Vascular Plug II (AVPII) for percutaneous closure of the right ventricular outflow tract via retrograde approach in an 18 month old child with double inlet left ventricle, normally related great arteries, and pulmonary stenosis, presenting with prolonged chylothorax following pulsatile BCPC. The narrowest RVOT diameter was 5.5mm, occluded with a 10mm AVPII device with stable result and no residual leak. Chylothorax resolved, and the child has been clinically well for nine months. Review of the literature revealed fourteen reported cases of effective transcatheter closure of ventriculopulmonary connections, 11 with an Amplatzer duct occluder, 3 Amplatzer septal occluders, and 1 Rushkind umbrella (one case required 2 devices). Twelve children were in good condition on follow up with clinical improvement, two had died non-procedure related deaths.

Conclusions: Residual ventriculopulmonary connections after a BCPC can be safely closed percutaneously using various devices. This is the first description of the use of the Amplatzer Vascular Plug II for occlusion of the right ventricular outflow tract. The multi-lobed, flexible quality of this device makes it particularly suitable for this procedure.