A 44 year-old female patient had medical history of ventricular septal defect since childhood and was regularly followed up at CV OPD. Ventricular septal defect (VSD) is a hole or a defect in the septum that divides the 2 lower chambers of the heart, resulting in communication between the ventricular cavities. It may occur as a primary anomaly, with or without additional major associated cardiac defects such as tetralogy of Fallot, complete atrioventricular canal defects, transposition of great arteries. Isolated small size VSDs close spontaneously by the age of 2 years, which is most frequently observed in muscular defects (80%), followed by perimembranous defects (35-40%). Unclosed VSDs causes left to right shunt, resulting in LV volume overload, aneurysm formation, aortic valve prolapse, pulmonary vascular disease…etc. Beside traditional treatment with open heart surgical repair, VSD occluder becomes an innovative choice of minimally invasive procedure. CV doctors got the vascular access through femoral artery and the ipsilateral femoral vein. The defect was measured at the end of diastole in the view that showed the best profile of the defect. Under transoesophageal echocardiographic and fluoroscopic monitoring, CV doctor delivered the device through the secure arteriovenous loop and push it to the defect location. The anesthesiologist checked the VSD occluder position, observing the presence of residual shunt, aortic regurgitation, and the tricuspid valve movement. The VSD occluder was deployed carefully. Repeated TEE and angiography were done which showed no malposition and other complications. The patient weaned the endotracheal tube immediately after the procedure at the catheter room then was sent to cardiovascular care unit for 24-hour hemodynamic intensive monitoring. She was discharged after 2 days smoothly.
With the expansion of Transcatheter Aortic Valve Implantation (TAVI) to intermediate risk patients, anesthesiologists will encounter more and more of these procedures. The trend from general anesthesia to sedation is a worldwide trend but highly depends on the experience of the surgeons and cardiologists. In more experienced hands, sedation technique is feasible. The need for transesophageal echocardiography (TEE) is not necessary because the results using fluoroscopy alone is comparable to that of TEE guidance. Hypercapnia is a big drawback of sedation, sometimes severe enough to cause narcosis or even hypoxemia. The effects could be detrimental to patients with preexisting pulmonary hypertension. While it is a general trend, anesthesiologists must be prepared to face catastrophes and prepare the tools for intubation as a final line of defense.