The paramount of three-dimensional echocardiography in percutaneous closure of large oval perimembranous ventricular septal defect: a case report

Background Ventricular septal defect (VSD) is the most common type of congenital heart abnormality with perimembranous VSD (pmVSD) accounting for similar to 70% of all VSD. Nowadays, transcatheter closure is the first choice for suitable pmVSD. However, there was no report about closing the large oval-shaped VSD percutaneously.Case summary A 34-year-old male with known VSD was referred for transcatheter closure after failed attempts in other hospital. Patient had been diagnosed with VSD at a young age, but he was lost to follow-up. He presented with shortness of breath due to heart failure and pulmonary hypertension. The initial measurement of the defect was 6-7 mm by transthoracic echocardiography (TTE), transoesophageal echocardiography (TEE), and LV angiography. However, re-measurement using TEE and 3D echocardiography revealed that the VSD is oval with diameters of 18 mm x 6 mm. Initially, device No. 12/14 was used, but it was dislodged on two attempts. The operator then decided to upsize the device size to No. 16/18 that was successful. The patient's condition was good, and 6 months follow-up after the procedure showed good outcomes without any residual defect or arrhythmia.Discussion In this study, we would like to highlight the rarity of large oval pmVSD that almost failed to be closed with the conventional measurement with echocardiography and fluoroscopy. Transoesophageal echocardiography especially 3D can be the new modality of choice that might be superior to fluoroscopy to decide the right device size in some cases such as oval-shaped pmVSD.