Setianto et al., 2015 80 Ventricular Septal Defect Closure with Perforated Patch in Large Ventricular Septal Defect with Severe Pulmonary Hypertension and Non Reactive Oxygen Test Budi Yuli Setianto, Hariadi Hariawan, Rano Irmawan Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Gadjah Mada – Dr. Sardjito Hospital, Yogyakarta, Indonesia Abstract Management of ventricular septal defect (VSD) with severe pulmonary hypertension (PH) had not been extensively studied and is still challenging. The closure of VSD in patients with high pulmonary vascular resistance (PVR) and severe PH is highly risk procedure. If high PVR and severe PH still persist after closure procedure, the patients have poor prognosis. We reported a 24-year-old woman whom was diagnosed with large VSD, bidirectional shunt with L to R dominance, dilatation of left ventricle, and mild to moderate mitral regurgitation, mild tricuspid regurgitation and severe PH. Right heart catheterization showed pre-oxygen test: mean aorta pressure 85 mmHg, mean pulmonary artery pressure 65 mmHg, flow ratio 5,4, PVR 2,3 WU and pulmonary vascular resistance index (PVRI) 3,22 WU/m 2 . The results of post-oxygen test: mean aorta pressure 83 mmHg, mean pulmonary artery pressure 63 mmHg, flow Ratio 2,2, PVR 0,3 WU and PVRI 0,42 WU/m 2 . Patient had been performed VSD closure with perforated patch 3 mm. Three month evaluation by echocardiography showed residual VSD 3 mm, L to R shunt, moderate tricuspid regurgitation and mild PH (TVG 36 mmHg). In Baumgartner criteria of VSD operability, this patient was not operable because the ratio of mean pulmonary and systemic circulation more than 2/3, but in Lopez criteria, patient is operable because PVRI below 6 WU/m 2 . Patient with high and moderate PH and PVR which is still operable, VSD can be closed partially. Partially VSD closure can be performed by transcatheter procedure after PH decrease and stable. Keyword: VSD closure- perforated patch – PH severe Background The management of ventricular septal defect (VSD) with severe pulmonary hypertension (PH) had not yet extensively investigated. 1 The closure procedure in VSD patients with increasing pulmonary vascular resistance (PVR) with severe PH is a risky procedure. The persistence of high PVR and severe PH after the closure procedure is the sign of a bad prognosis. 1 In a restropective study, patient with congenital heart disease and severe PH post operatively had worse prognosis than patient with non-operative congenital heart disease. 2 In this case we present and discuss a patient with large VSD, severe PH and non reactive oxygen test in whom the VSD closure was performed. Case A woman 24 years old came to our hospital with a chief complaint of dyspnea. She felt dyspnea on effort since 10 months before admission, there was neither orthopnea nor paroxysmal nocturnal dyspnea. Patient had been diagnosed as large VSD since April 2014 and has been planned to have VSD closure. Her physical examination demonstrated a good general condition and compos mentis. Blood pressure was 100/60 mmHg, heart rate was 82 bpm, respiratory rate was 22 x/minute, temperature was 36,5⁰C and peripheral oxygen saturation was 97%. No increased jugular venous pressure. Lung examination was normal. There was cardiomegaly with ictus cordis at intercostal space V left mid clavicula line. In auscultation, S1 was normal and S2 was louder, with holosystolic murmur grade 3/6 with punctum maximum at intercostal space III-IV left parasternal border. Abdominal and extremity examination were normal Laboratory results showed hemoglobin 13,1 g/dL, hematokrit 39%, leukocytes 7,94 x 10 3 /μL, segment 59,6 %, limphocytes 31,6 %, monocytes 6,9%, eosinophil 1,8%, basophil 0,1%. Blood chemistry showed BUN 11 mg/dL, creatinine 0,89 mg/dL, SGOT 21 U/L, SGPT 18 U/L, natrium 138 mEq/L, potassium 3,8 mEq/L, and chloride 102 mEq/L. An electrocardiography examination showed sinus rhythm, heart rate 76 bpm and normoaxis (figure 1).