Editorial Comment

Keep Plugging Along!

Victor Lucas, MD

Pediatric Cardiology, Ochsner ClinicFoundation, New Orleans, Lousiana

In this case report, Dr. Narula et al. report anotherinnovative use of an Amplatzer device accomplishingpercutaneous closure of a persistent vertical vein in apatient with surgically repaired supracardiac totalanomalous pulmonary vein connections. Right heartvolume overloads as a result of left to right shuntthrough the persistent anomalous vein indicated clo-sure. Attempts at earlier vein closure by surgery failedbecause of insufficient left heart compliance.

Device closure of the newly apparent ‘‘persistent’’left superior vena cava in post-Fontan patients withhigh central venous pressure is a more widely reportedprocedure of a similar nature. The compliance of thevein in this situation can make fixation of any devicechallenging. In the case reported herein, the prior sur-gical banding of the vertical vein presented a favorabletarget for the Amplatzer PDA device aortic retentiondisc and limited or eliminated dynamic changes invein diameter. While there is likely to be generalagreement amongst pediatric cardiologists favoring de-vice based closure instead of surgery in this patient, itis worth remembering that complications with this

approach are certainly possible. Device embolization

may not be predictable in compliant structures and is

not without significant risk. The PDA device can be

somewhat difficult to retrieve once released because of

the need to grasp the recessed screw to enable easy

withdrawal into a small sheath. Erosion into or inter-

ference with nearby structures (left bronchus, laryngeal

and vagus nerves, and pulmonary artery) may be im-

portant. An antiplatelet strategy similar to that used for

ASD closures seems likely to produce favorable

results. The currently available vascular plug seems

poorly suited for this application. Placement of a cov-

ered stent in the left innominate vein across the entry

site of the vertical vein may be a viable alternative

approach in some patients.This report serves to highlight again the versatility

of the Amplatzer occlusion devices. Device and cableimprovements including easier ‘‘deliverability,’’ lowerprofile, increased thrombogenicity of the vascular plugtype devices, and enhanced device to vessel ‘‘grip’’ atrelatively low expansile forces are awaited eagerly.When widely available, muscular VSD type Amplatzerdevices with two retention discs may be useful forsimilar applications when there is more concern aboutpossible bidirectional flow forces on the device.Percutaneous device closure of unwanted vessels has

evolved to the point that surgery is rarely the favoredoption. The authors are to be commended for sharingthis interesting case. Keep pluggin!

Correspondence to: Victor Lucas, MD, Pediatric Cardiology,

Ochsner Clinic Foundation, 1315 Jefferson Hwy., New Orleans,

Louisiana 70121. E-mail: vlucas@ochsner.org

Received 13 April 2007; Revision accepted 14 April 2007

DOI 10.1002/ccd.21237

Published online 22 June 2007 in Wiley InterScience (www.interscience.

wiley.com).

' 2007 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 70:120 (2007)