Transcatheter occlusion of moderate to large patent arterial ducts with the Amplatzer ductal occluder device is safe and effective, with a high rate of complete occlusion. Problems and minor complications may be encountered in children weighing less than 10 kilograms. If the device is to be deployed completely in the ductal ampulla, and to avoid descending aortic obstruction, the size of the retention flanges of the occluder should not exceed the largest diameter of the patent arterial duct.

Galal et al: Transcatheter closure of arterial duct 523 device reported by Rashkind and Cuaso. 6 Initial success with the Rashkind device suggested that it might well be the management of choice. The double umbrella, however, was unwieldy, and required a large bore sheath for its introduction. When used to close large ducts in small children, there was also a risk of causing left pulmonary arterial stenosis or aortic narrowing. Moreover, the device was suitable only if the narrowest diameter of the duct was less than 9 millimetres. About half of patients with persistently patent ducts, therefore, would have still needed surgical ligation. 7 By the early 1990s, Cambier et al. 8 had led the way in using Gianturco coils to close small ducts. Such coils were much less cumbersome than the umbrellas, and hence found rapid worldwide acceptance. But such coils were still of use only in smaller ducts, measuring less than three millimetres at their narrowest diameter. The closure of larger ducts using multiple coils was appealing, and often proved to be successful, but was associated with an increased risk of left pulmonary arterial stenosis, 9 and a relatively high rate of inadvertent embolization. 10 The introduction of the Cook detachable coil provided an even safer option, 11 and this device almost entirely replaced the Gianturco coil for closing small duct. Then, in 1993, the PFM coil was introduced for clinical use. It has since undergone several modifications, but clinical experience is now encouraging when it is used for closing the small and moderate patent arterial duct. 12 Despite these developments, the large ducts still remained in the domain of the surgeon. Rao et al., 13 as well as later Grifka et al., 14 designed devices to close such larger ducts, but neither device emerged as a significantly marketable option. It was the emergence of the Amplatzer duct occluder that expanded the options of the interventional cardiologist. This device is currently used safely and effectively for closure of ducts measuring up to 16 millimetres at their narrowest diameter.

This study presents technique and initial experience of retrograde deployment of the Amplatzer muscular ventricular septal defect occluder (AmVSDo) for closure of muscular ventricular septal defects (VSDs). The conventional technique for closing muscular VSDs involves the creation of an arteriovenous guidewire circuit and use of a transvenous approach for device deployment. Seven patients aged 2.2-15 years underwent transcatheter closure of a muscular VSD using the retrograde approach without making the arteriovenous wire circuit. Mean fluoroscopy and procedural times were compared to those previously reported in publications describing the use of the antegrade approach. Unpaired Student's t-test was used to compare the two parameters in two groups. Our technique was successful in all patients reported. The mean fluoroscopy time in the retrograde versus the antegrade group was 33.8 +/- 20.9 and 41.9 +/- 6.2 minutes, respectively (not significant), and the mean procedural time in the two groups was 91.1 +/- 22.1 and 114 +/- 33.9 minutes respectively (p = 0.025). No complications were noted. We suggest that some muscular VSDs can be safely closed retrogradely without the use of an arteriovenous loop, thus reducing the radiation exposure and also the cost of the procedure. Further studies are needed to confirm this initial experience.

Management of neonatal native coarctation is debated till now. Surgical therapy remains an option but may be unwarranted in critically sick infants with complex lesions. Balloon dilatation has been employed but with early re-stenosis. Stent angioplasty has also been used but as a bridge towards definitive surgical therapy. Four critically sick infants with complex coarctation and additional co-morbidity factors underwent primary stent therapy as surgical intervention was denied. One patient had died earlier due to reasons unrelated to the procedure. Three survivors underwent multiple dilatations of primary stents as indicated. One of the three survivors did not require any further dilatation after the age of 5 years and remained stable till the time of reporting. High-pressure Cheatham Platinum stents were implanted inside the primary stents in two infants, who developed re-stenosis due to somatic growth. These stents were further balloon dilated at high atmospheric pressure. Femoral arteries in both of them were blocked but were re-canalized after balloon dilatation in one and stent angioplasty in the other. After a follow-up of about 15 years, all of them have been doing fine with acceptable Doppler gradients. They were normotensive and on no cardiac medications. It can be concluded that, though surgical repair remains a standard of care, stent angioplasty in selected infants with complex lesions is feasible and effective. Multiple dilatations can be performed without added risk of stent migration. Bio-absorbable and growth stents hold a promise for future use in such situations.

The term cor triatriatum is used to describe a fibromuscular partition that divides an atrium into two compartments. It was first used by Borst in 1905, although the lesion had been described before by Church in 1868. Both described divided left atrial chamber (also referred to as cor triatriatum sinister). The incidence of the divided left atrial chamber among patients with congenital heart disease is reported at 0.1% and 0.4% in an autopsy study. Divided right atrial chamber - also referred to as cor triatriatum dexter - is even rarer to an extent that there is no reported incidence and only few hundred cases have been reported so far. A search through pubMed library revealed only 90 publications on humans, either under the term "dexter" or "dextrum". We would like to report a new association of bilateral divided atrial chambers and pulmonary vein stenosis, with a review of the literature.