Case Report Transcatheter Closure of Large Patent Ductus Arteriosus Using Custom Made Devices Manoj Kumar Rohit, MD, DM and Ankur Gupta, * MD, DM There has been a paradigm shift in the transcatheter closure of patent ductus arterio- sus (PDA) over the last 45 years. With the availability of various coils, plugs and occluders, PDA of almost all shapes and sizes are amenable to transcatheter closure. However, very large PDA diagnosed late in life are being referred for surgical closure in the absence of availability of large size devices, especially in developing countries. In this case series, we have described four patients with large PDA, three of which were closed by transcatheter custom made PDA occluders. V C 2013 Wiley Periodicals, Inc. Key words: congenital heart disease in adults; fistula/shunts; hemodynamics; pediatric interventions INTRODUCTION Transcatheter closure of patent ductus arteriosus (PDA) is a simple, safe, and effective procedure, being done throughout the world. Since the first use of Ivalon plug in 1967 [1], no other shunt lesion has seen so much advancement in the development of device tech- nology as PDA, the latest being the second generation Amplatzer vascular plugs (St Jude Medical, Plymouth, IN). However, the maximum sizes available amongst the commonly used devices are 16/14 mm for Amplat- zer duct occluder I (AGA Medical corporation, Golden Valley, MN), 22 mm for Amplatzer vascular plug II, and 24/22 mm for Cera PDA occluder (Lifetech Scien- tific, Shenzhen, China). In developing countries, many patients with large PDA present late in life. In the absence of large size devices, the option left for these patients is surgical li- gation. Here we report four patients with large PDA and their transcatheter closure with custom made large PDA occluder or muscular ventricular septal defect (VSD) occluder. CASE 1 A 16-years-old patient was referred with an inciden- tally detected murmur. On examination, she had a con- tinuous murmur in the left first and second intercostal space. Echocardiography showed a large PDA with enlarged left atrium (LA) and left ventricle (LV) and preserved left ventricular systolic function. There was no tricuspid regurgitation (TR). After an informed con- sent, she was taken up for cardiac catheterization and device closure. Both femoral artery and vein were accessed after giving local anesthesia. Hemodynamic study revealed pulmonary artery systolic pressure (PSAP) of 48 mm Hg, systemic systolic pressure of 130 mm Hg, Qp/Qs of 2.83, and Pulmonary Vascular Resist- ance (PVR)/Systemic Vascular Resistance (SVR) of 0.09. Descending aortogram was done using a 6 F pig- tail catheter (Cordis Corporation, FL) and ductus size was measured to be 15 mm in lateral view (Fig. 1). Af- ter crossing the PDA from pulmonary artery side using a Multipurpose catheter (Cordis Corporation), a 0.035 inch, 260 cm Amplatzer extra stiff guidewire (AGA Medical Corporation, Golden Valley, MN) was intro- duced. A 14 F cook delivery sheath (Cook, Department of Cardiology, PGIMER, Chandigarh, India Conflict of interest: Nothing to report. *Correspondence to: Ankur Gupta, Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: ag_pgi@yahoo.com Received 5 August 2013; Revision accepted 27 November 2013 DOI: 10.1002/ccd.25349 Published online 00 Month 2013 in Wiley Online Library (wiley onlinelibrary.com) V C 2013 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions 00:00–00 (2014)