Off-Label 16-mm VSD Occluder for Closure of a Giant PDA With Severe Pulmonary Hypertension

BACKGROUND: Giant patent ductus arteriosus (PDA) with pulmonary hypertension often presents unique challenges for closure, requiring extensive expert team discussion. CASE-SUMMARY: A 17-year-old girl with syncopal episodes, intermittent chest pain, and continuous cardiac murmur was diagnosed with a 12.5-mm PDA. After a few months of pulmonary vasodilator therapy, pulmonary vascular resistance (PVR) improved from 7 WU to 5.5 WU, and treatment with closure using a 16-mm ventricular septal defect (VSD) occluder proceeded. Post-procedure, symptoms resolved along with left ventricular remodeling. DISCUSSION: Off-label use of VSD occluders is increasing for treatment of large PDAs. In high-risk patients, careful hemodynamic assessment, trial occlusion, and staged pulmonary vasodilator therapy optimize outcomes. For controversial borderline PVR (5-8 WU), closure decisions should rely on comprehensive evaluation by adult congenital heart disease and pulmonary hypertension specialists rather than PVR alone. TAKE-HOME MESSAGES: Muscular VSD occluders provide a viable alternative for large PDA closure with complex anatomy. In borderline PVR (5-8 WU), decisions should rely on comprehensive evaluation by adult congenital heart disease and pulmonary hypertension specialists rather than PVR alone.