Retrograde closure of perimembranous ventricular septal defects. A paradigm shift

To the Editor, The percutaneous closure of ventricular septal defect (VSD) is still not widely used today due to its potential complications (atrioventricular block, valvular heart disease, hemolysis), and technical limitations, particularly, in low-weight patients.1 Devices specifically designed for the closure of perimembranous VSD (pmVSD) have an asymmetric design that conditions implantation via antegrade venous access. Therefore, the standard procedure requires creating an arteriovenous loop across the defect to advance the device until its sequential release from the aorta or the left ventricle. An example of this is the Nit-Occlud Lê VSD-Coil device (PFM Medical, Germany) that has a good safety and efficacy profile.2 However, the creation of the loop can be the cause for transient atrioventricular blocks and hemodynamic instability especially in low-weight patients.3 Also, the use of different unspecific occluders—with good clinical outcomes—for this indication has been described, especially if the defect comes with aneurysmal tissue.4 Thanks to their symmetric design and low profile, some devices can be released from the arterial side (retrograde), thus avoiding the creation of the loop. This simplifies the technique, shortens procedural time, and minimizes the dose radiation received by the patient. Such approach has already been described with good clinical outcomes with a specific design...