Late Surgical Explantation of an Amplatzer Duct Occluder-II (ADO II) in an Adolescent with Persistent Residual Perimembranous Ventricular Septal Defect and Tricuspid Septal Leaflet Adherence: A Case Report

Background : Transcatheter closure is an established treatment option for selected perimembranous ventricular septal defects (VSDs). Because of the close anatomical relationship of the perimembranous septum to the tricuspid valve, aortic valve, and conduction system, residual shunting and device–valve interactions remain important considerations during follow-up.
Case Presentation : A 14-year-old boy was referred in 2026 with progressive exertional dyspnea and occasional chest discomfort. Four years earlier, on February 5, 2022, he had undergone transcatheter closure of a perimembranous VSD at another institution using a 6/6-mm Amplatzer Duct Occluder II (ADO II). The available procedural record documented catheter-based VSD crossing, device deployment, and immediate transesophageal echocardiographic assessment before release, with satisfactory device position reported. The original catheterization laboratory fluoroscopic, angiographic, and echocardiographic images were unavailable for retrospective review. Follow-up echocardiography in 2023 and 2024 demonstrated a persistent residual VSD of approximately 5 mm without significant tricuspid regurgitation (TR) or pulmonary hypertension, and surgical closure had been advised. In 2025, the patient developed mild exertional dyspnea, which progressed to New York Heart Association (NYHA) functional class II symptoms by 2026. Preoperative transthoracic echocardiography demonstrated a 6–7-mm residual perimembranous VSD inferior to the device, with predominantly left-to-right flow and a peak Doppler gradient of approximately 87 mmHg. Ventricular systolic function was preserved, without significant TR or pulmonary hypertension. Following multidisciplinary assessment, surgery was undertaken because of the persistent residual defect, previous recommendations for definitive closure, evolving symptoms, and the anatomical relationship of the device to the tricuspid septal leaflet, with repeat transcatheter intervention considered limited and of uncertain feasibility. Surgical exploration demonstrated the ADO II between the tricuspid septal leaflet and the right-ventricular aspect of the interventricular septum, with adherence to the septal leaflet and localized leaflet distortion. The leaflet was structurally intact. The device was carefully explanted, the residual VSD was directly closed, and the distorted tricuspid septal leaflet was repaired. Intraoperative transesophageal echocardiography demonstrated complete VSD closure and satisfactory tricuspid leaflet coaptation with mild TR. At 6-month follow-up, the patient had no dyspnea or breathing difficulty, with persistent VSD closure, preserved ventricular function, and stable mild TR.
Conclusion : This case documents a late operative device–tricuspid anatomical relationship following ADO II closure of a perimembranous VSD. The principal finding was the location of the device between the tricuspid septal leaflet and the right-ventricular aspect of the interventricular septum, with leaflet adherence and localized distortion despite the absence of significant preoperative TR. Because the original implantation imaging was unavailable, the timing and mechanism of this relationship cannot be established. Furthermore, the restrictive residual VSD, preserved ventricular function, and absence of pulmonary hypertension or major ventricular volume loading do not establish the residual shunt as the direct cause of the patient's exertional symptoms. Surgical exploration permitted simultaneous device explantation, definitive VSD closure, and restoration of tricuspid leaflet coaptation, with satisfactory short-term outcome.

Ventricular Septal Defect Amplatzer Duct Occluder II Residual VSD Transcatheter Closure Tricuspid Septal Leaflet Device Adherence Surgical Explantation Congenital Heart Disease

Ansari ZR, Hamdulay ZA, Khan A, Jain S, Hamdulay M. Late Surgical Explantation of an Amplatzer Duct Occluder-II (ADO II) in an Adolescent with Persistent Residual Perimembranous Ventricular Septal Defect and Tricuspid Septal Leaflet Adherence: A Case Report. International Journal of Evidence-Based Medicine. 2026;1(4):jebm017. https://doi.org/10.63946/jebm/19636