Discussion

As the large APW carries a high risk for cardiac failure and irreversible pulmonary vascular disease, surgical or transcatheter closure is required at early ages. Although the conventional treatment is surgery, successful PC procedures have been reported in the literature, since 1995. The potential risks of the PC of a large APW in low-weight infants include damage to the semilunar valves by the device discs and the possibility of device protrusion into the arterial lumen and risk of coronary compression.[3,4] Selection of the device is important in infants to avoid these complications. There are only a few reports in the literature about the PC of large APW in small infants.[3-6,9,10] Trehan et al.[4] reported three symptomatic infants with large defects (8 to 10 mm), and two were intermediate-type windows, closed by duct and muscular VSD occluders, while the third was the window with a mild inferior rim deficiency, closed by a perimembranous VSD occluder. The authors recommended this device, owing to its relatively flat profile (a waist diameter of 1.5 mm), and asymmetric discs suitable for closure of an APW with some deficiency. Kosma? et al.[9] used a 5-mm perimembranous Amplatzer? VSD occluder device (St. Jude Medical Inc., MN, US) for the intermediatetype APW of a 3,600 g newborn. They considered that the tunnel-shaped anatomy of the patient"s defect facilitated the positioning of the device. In another case report, Sabnis et al.[5] reported the closure of a 4.4-mm defect with adequate rims using an 8-6 Amplatzer? duct occluder (ADO; St. Jude Medical Inc., MN, USA) in a 2,600-g newborn. Although there are a few successful closure reports in the literature, duct occluders tend to protrude toward the main pulmonary artery, thus carrying a risk of obstructing the vessel and coronary artery.[3,4,9] Atrial septal defect occluders with very large rims, on the other hand, may obstruct the semilunar valves or left coronary ostium, due to their bulky device structure; therefore, these devices seem to be inappropriate for patients with a low weight and large APW.[3,4]

The proximal and distal type small APW can be closed by the ADO? II additional sizes. This device seems to be suitable for the PC of small defects (<4 mm) in close proximity to pulmonary bifurcation, aortic valve and/or coronary ostium, thanks to its smaller disc size, which minimizes the risk of obstruction of vessel lumen, semilunar valve, and left coronary artery.[7,8] A lternatively, Odemis et al.[10] used a 7-mm Nit-Occlud® P DA-R d evice ( BVM M edical L td., Leicestershire, UK) and successfully closed the APW, type I defect of 5 mm, in a three-month-old patient. They offered this device owing to its lower profile, requiring smaller sheet sizes, and the completely flat retention disk. Despite limited experiences, its small skirt at the distal side and very flat design may provide the advantage of reducing the risk of compression on the coronary arteries.

The type, size, and location of the defect, suitability of the device to be selected, and the body weight of the infant are critical factors in the selection of an appropriate device. The ideal device for PC of APW should be double-disc with a short waist and short skirt rim, thereby, reducing the risk of protrusion into the pulmonary artery and compression of coronary artery and requiring a small sheath. Therefore, in the present case, we preferred a 7-mm symmetric membranous VSD occluder device (waist length: 3 mm, right disc: 11 mm and left disc: 11 mm) through its short waist and two equal and short retention discs (only 2 mm for each side) and the device was fitted to the defect. After the procedure, we observed no residual shunt or complications such as protrusion into the pulmonary vessels or compression onto the coronary arteries. In addition, requirement of a small 6Fr sheath prevented the damage to the small vessels of the infant.

During the procedure, we passed directly from the antegrade route using a soft hydrophilic guidewire and a 5Fr right Judkins catheter from pulmonary artery to ascending aorta. This technique facilitated the procedure and the procedure completed without using a snare in a short time. In our technique, we used only 4Fr sheath in the arterial side and we used the arterial way to show defect before and after releasing the device. Of note, the interventional cardiologist should know the properties of the materials at shelf and choose the most appropriate one according to each individual case. In addition, a flexible strategy should be followed according to the characteristics of the case and the easiest and simplest way should be preferred, particularly in infants.

In conclusion, it is challenging to choose the appropriate device and, to date, there is no consensus on the choice of an optimal device for aortopulmonary window closure. The intermediate type, as in our patient, consists of a central defect with adequate superior and inferior rims, which makes it most suitable for percutaneous closure. We recommend the symmetric membranous ventricular septal defect occluder and antegrade passing technique as a safe and effective alternative to surgery for percutaneous closure of aortopulmonary window in infants with large defects soon after the diagnosis.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

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