case_images: PMC4782470_01
case_images: Chest X-ray showing mild cardiomegaly and very minimal pulmonary plethora
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case_images: F1
case_images: The chest X-ray showed minimal cardiomegaly, dilated central pulmonary arteries, and a minimal plethora [Figure 1]. There was a very large 10 mm PDA shunting left to right predominantly without any gradient from the aorta to the pulmonary artery and very minimal left atrial and ventricular enlargement [Figure 2, Movie 1].
case_images: Color Doppler echocardiogram shows laminar left to right flows across a large patent ductus arteriosus in parasternal short axis view [Movie 1]
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case_images: F2
case_images: There was a very large 10 mm PDA shunting left to right predominantly without any gradient from the aorta to the pulmonary artery and very minimal left atrial and ventricular enlargement [Figure 2, Movie 1]. The large tubular duct measured 10 mm on lateral view aortogram and was similar in size to the descending thoracic aorta below the duct [Figure 4, Movie 2].
case_images: Simultaneous aortic and pulmonary artery pressure tracing on oxygen (a) Severe pulmonary arterial hypertension with no differences in systole and diastole. Following test occlusion with the device, there was a good fall of pulmonary artery pressures (b) And separation from the aortic pressures
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case_images: F3
case_images: During cardiac catheterization on conscious monitored sedation with ketamine, the pulmonary arterial and aortic pressures were similar both in room air breathing and on oxygen [Figure 3a]. Test occlusion with a 16 mm muscular VSD device (Cera muscular VSD occluder, Lifetech Scientific, Shenzhen, and PRC) caused significant reduction in pulmonary artery pressure and its separation from aortic pressures [Figure 3b]. The VSD device was deployed in the usual way with a stable position [Figure 6a, Movie 3 and Movie 4].
case_images: Lateral view aortogram showed a very large 10 mm tubular patent arterial duct which was similar in size to the descending thoracic aorta [Movie 2]
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case_images: F4
case_images: The large tubular duct measured 10 mm on lateral view aortogram and was similar in size to the descending thoracic aorta below the duct [Figure 4, Movie 2]. The VSD device was deployed in the usual way with a stable position [Figure 6a, Movie 3 and Movie 4].
case_images: A central puncture was made through the fabric of a 16 mm muscular ventricular septal occluder device with 18G needle, and an 8F dilator was passed over a 0.035  wire through the device
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case_images: F5
case_images: A short 8F dilator was passed over the wire to make the fenestration larger to allow passage of a 5 French right coronary guiding catheter (Launcher, Medtronic Inc., Minneapolis, Minnesota) [Figure 5].
case_images: Fluoroscopic lateral view (a) A stable position of the 16 mm Muscular ventricular septal defect device across the patent ductus arteriosus while a combination of 5F right coronary guiding catheter with guide wire is passing through the center of the device. Descending aortic angiogram in lateral view (b) Filling of pulmonary artery through the stent [Movie 4]
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case_images: F6
case_images: The VSD device was deployed in the usual way with a stable position [Figure 6a, Movie 3 and Movie 4]. Post-procedure fluoroscopy and an angiogram showed good device and stent position with good descending aortic flows [Figures 6b and 7; Movie 5].
case_images: Fluoroscopic image in anteroposterior view showing opened coronary stent orifice enface in the middle of the occluder [Movie 5]
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case_images: F7
case_images: Post-procedure fluoroscopy and an angiogram showed good device and stent position with good descending aortic flows [Figures 6b and 7; Movie 5].