(LVEDD) z-score of more than +3.8. Rest of finding was normal, final impression was large upper muscular VSD with severe pulmonary hypertension (PAH) with evidence of LA and LV dilation.

Procedure At first surgical closure was offered to the patient given refractory congestive heart failure (CHF) and positive history of recurrent lower tract infection (LRTI), out of which the last admission was life-threatening for which the patient was intubated and kept ventilated for six days. With this background, the case was discussed in detail with the cardiovascular surgical team and parents.

The most prominent concerns to go for surgical closure of VSD with this patient was low weight and the need for prolonged postoperative care. Finally, after considering all these issues, it was decided to go for device closure without giving general anesthesia(GA) and also avoiding intubation for obvious reasons. More importantly, encouraging fact with this patient was the location of VSD (upper muscular, distant from tricuspid and aortic valve) and the accessibility of low profile and soft hardware urged us to endeavour VSD device closure with the expectation of utilizing the Amplatzer duct occluder II 6/4 (Abbott, USA).

The technique was performed under conscious sedation (intentionally planned)with a full backup of intubation and provision of general anesthesia (GA). After acquiring femoral venous access (5F) and femoral arterial access (5F), a hemodynamic assessment was first performed to get pressures and saturations.

Figure 4 Echo images depicting (a) significant shunt across the ventricular septal defect, grossly dilated left atrium and left ventricle (b)

Figure 5. Showing crossed VSD from LV side, crossed wire is parked in deep LPA

The 6X 4 mm Amplatzer Duct Occluder (II) was deployed under fluoroscopic and transthoracic echocardiography guidance. Finally the device was released which took its predestined shape.

Post-procedure TTE showed the device to be perfectly in place and there was no residual flow. Formation of AV loop and introduction of the long sheath was avoided with this technique. (Fig 6). Total procedure time was around 25 min and fluoroscopy time was 10 min.

Figure 6 Deployment of device

Figure. 7 showing excellent device position

Follow up

After fourteen days, the child began to put on weight (2.8 kg). Only in 20 days all CHF medication was stopped, there was improved oral intake, his symptoms( fast breathing ) was resolved in few days. On follow up Echo there was no residual shunt, no AR, TR and no pericardial effusion. however long term follows up is required.

Transcatheter closure of VSD was described in the last part of the 80s and mid-90s [2–3]. While the closure of muscular VSD discovered acknowledgement, it was the perimembranous VSD, which came into dishonour, with past investigations tracking down a high pace of complete atrioventricular block associated with this method [4]. By and large transcatheter closure has been restricted to body weight over 10 kg [5]. Our patient had a bodyweight of 2.3 kg, and for him surgical closure was the first-line treatment option at any given point in time.

The realities were that the patient could not thrive and also he was admitted twice to the emergency unit with congestive heart failure and LRTI which makes him not a decent candidate to go through CPB (cardiopulmonary bypass) which was needed for surgical closure. This urged us to opt for a less invasive option and also the location of VSD (upper muscular, away from TV, AV) made the danger of heart block with transcatheter approach far-fetched because any device placed will be away from the conduction tissue [6].

Off-label utilization of Amplatzer ductal occluders in Perimembranous VSD has been accounted for [7]. As the size of VSD was 4.5 mm, we chose a 6×4 mm duct occluder (ADO II). If anatomy (size and location) of defect can be nicely established on echo, it’s always better to avoid LV angiogram in such small babies as it would reduce the total duration of the procedure and also avoid the injection of contrast agent into the body.

AV loop formation is not free from risk as it stents the small heart like this patient, it’s always better to avoid forming an AV loop and taking larger, longer sheath from the venous side, rather its safer to deploy the device from arterial side (retrograde)in these small babies.