Multicenter experience with perventricular device closure of muscular ventricular septal defects

Intraoperative device closure of postinfarction ventricular septal defects

Postinfarction ventricular septal defects (VSDs) are associated with high mortality and typically these are treated urgently with surgery for exclusion patch repair. Percutaneous closure of postinfarction VSDs using occlusion devices is feasible in some patients, but in some cases device deployment may not be possible due to VSD anatomy or valvular apparatus interference. We report the novel technique of deploying Amplatzer VSD devices in the operating room under direct vision through a right atriotomy with and without aortotomy in 2 patients with large inferobasal VSDs after myocardial infarction.

Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass: multicenter experience and mid-term follow-up

OBJECTIVE

To summarize the clinical experiences and mid-term follow-up results of perventricular closure of perimembranous ventricular septal defect without cardiopulmonary bypass under transesophageal echocardiography guidance.

METHODS

A total of 408 patients with perimembranous ventricular septal defects, aged 5 months to 15 years (3.1 +/- 1.7 years) with a body weight of 4.5 to 26 kg (13.6 +/- 5.5 kg), underwent perventricular device closure. The procedure was performed via a small lower sternal incision. A guidewire was inserted through the ventricular septal defect to the left ventricle under transesophageal echocardiography guidance after a pursestring suture was placed on the right ventricular free wall. A modified delivery sheath was introduced over the guidewire to establish the delivery pathway. Proper devices were delivered and then deployed if no atrioventricular or aortic valvular disturbance, or residual shunt was detected by transesophageal echocardiography. Patients were followed up with a standard protocol, which is once every month in the first 3 postoperative months and then once every 3 months with echocardiography, electrocardiography, and chest radiography in each follow-up.

RESULTS

A total of 393 patients in this group underwent successful closure (96.3%), and the procedure was converted to conventional open repair in 15 patients (3.7%). A total of 213 symmetric devices (54.2%) and 180 asymmetric devices (45.8%) were implanted. Only 6 of the 393 patients (3.5%) received transfusion of blood products. New trivial or mild tricuspid regurgitation was found in 13 patients (3.3%), and there was no worsening of regurgitation in those patients with existing tricuspid regurgitation before operation. Eleven patients (2.8%) had incomplete right bundle branch block. Most of the patients were discharged 3 to 5 days after the operation. Follow-up in all patients ranged from 3 months to 2 years (14.6 +/- 6.2 months) and revealed no residual shunt, new or aggravating aortic regurgitation, obstruction of left or right ventricular outflow tract, or device dislocation.

CONCLUSION

Minimally invasive perventricular device closure of ventricular septal defect without cardiopulmonary bypass is a simple, effective, and relatively safe intervention under guidance of transesophageal echocardiography. This method should be considered for patients with ventricular septal defect. Long-term follow-up is necessary.

Novel method for delivering the Amplatzer muscular VSD occluder in a patient with double outlet right ventricle after bidirectional Glenn procedure and pulmonary artery band

We report the first use of bilateral femoral venovenous rail creation for the delivery of an Amplatzer Muscular Ventricular Septal Defect Occluder in a patient with a large mid-to-apical muscular ventricular septal defect before Rastelli operation. The presence of a right-sided bidirectional Glenn shunt, a banded main pulmonary artery, and double outlet right ventricle anatomy precluded the use of standard delivery techniques. The patient underwent successful transcatheter device placement followed by Rastelli operation on the following day.

Advances in paediatric interventional cardiology since 2000

Interventional paediatric and congenital cardiology is expanding at a rapid pace. Validated techniques (such as aortic or pulmonary valve dilatations and occlusion of persistent ductus arteriosus and atrial septal defects) are improving thanks to the use of smaller introducers and sheaths, low-profile balloons and novel devices. Moreover, catheter-based interventions have emerged as an attractive alternative to surgery in other fields: pulmonary valve replacement, balloon and stent implantation for native and recurrent coarctation, and percutaneous closure of ventricular septal defects. On the other hand, percutaneous interventions in the paediatric population may be limited by patient size or the anatomy of the defect. Hybrid approaches involving both cardiac interventionists and surgeons are being developed to overcome these limitations. Based on a better understanding of cardiac development, fetal cardiac interventions are being attempted in order to alter the history of severe obstructive lesions. Finally, some interventional procedures still carry a low success rate-for example, pulmonary vein stenosis, even with the use of conventional stents. Biodegradable stents and devices are being developed and may find an application in this setting as well as in others. The purpose of this review is to highlight the advances in paediatric interventional cardiology since the beginning of the third millennium.

Pediatric cardiac interventions

The field of pediatric cardiac interventions has witnessed a dramatic increase in the number and type of procedures performed. We review the most common procedures performed in the catheter laboratory. Lesions are divided according to their physiological characteristics into left-to-right shunting lesions (atrial septal defect, patent ductus arteriosus, ventricular septal defect), right-to-left shunting lesions (pulmonary stenosis, pulmonary atresia/intact ventricular septum), right heart obstructive lesions (peripheral arterial pulmonic stenosis, right ventricular outflow tract obstruction), and left heart obstructive lesions (aortic valve stenosis, coarctation of the aorta). In addition, a miscellaneous group of lesions is discussed.

Teaching the "hybrid approach": a novel swine model of muscular ventricular septal defect

This report describes a reproducible swine model for creating muscular ventricular septal defects (VSDs). The model not only facilitates the development and modification of hybrid techniques for closing muscular VSDs, but also serves as a teaching tool that allows operators to become accustomed to the specific technical requirements necessary when using the hybrid approach to perform periventricular VSD device closure. The authors' institutional experience using this novel animal model is presented.

Minimal incision congenital cardiac surgery

Minimally invasive techniques have had limited application in congenital cardiac surgery, primarily due to the complexity of the defects, small working area, and the fact that most defects require exposure to intracardiac structures. Advances in cannula design and instrumentation have allowed application of minimal incision techniques but in most cases, cardiopulmonary bypass is still required. Image guided surgery, which uses noninvasive imaging to guide intracardiac procedures, holds the promise of permitting performance of reconstructive surgery in the beating heart in children.

Clinical efficiency and safety analysis of transcatheter interventional therapy for compound congenital cardiovascular abnormalities

OBJECTIVE

To investigate the efficiency and safety of transcatheter interventional therapy for compound congenital cardiovascular abnormalities.

METHODS

From Nov 2001 to Jun 2006, a total of 36 patients (17 male, 19 female), aged 17.20 +/- 10.52, with compound congenital cardiovascular abnormalities underwent transcatheter interventional procedure. These patients included 11 with perimembranous ventricular septal defect (PVSD) and patent ductus arteriosus (PDA), 8 patients with PVSD and atrial septal defect (ASD), 8 patients with ASD and PDA, 7 patients with ASD and pulmonary stenosis (PS), 1 patient with ASD and mitral stenosis(MS), 1 patient with coarctation of aorta (COA) and PDA. According to the principle of "easy first, hard second," balloon valvuloplasties of PS or MS were performed before the closure of PVSD, and of PDA and ASD. Electrocardiogram and transthoracic echocardiogram were examined at 4 days, 1, 2, 6 and 12 months, respectively, after each procedure.

RESULTS

Transcatheter interventional therapy for compound congenital cardiovascular abnormalities was successful in all patients. Among these, 2 occluders were planted in each of 27 patients, 7 patients with ASD combined with PS and 1 patient with ASD combined with MS underwent successfully performed balloon valvuloplasty and ASD closure, 1 patient with COA combined with PDA underwent successfully performed balloon valvuloplasty and subsequent covered stent implantation. No patient encountered serious adverse events during the (30.5 +/- 14.6) months of follow-up.

CONCLUSIONS

Transcatheter interventional therapy for compound congenital cardiovascular abnormalities could obtain satisfactory results with technical feasibility.

Percutaneous closure of ventricular septal defects

BACKGROUND

Surgical closure of ventricular septal defects has been performed for many years, and is considered as the gold standard for treatment. It remains associated with morbidity and mortality. Transcatheter techniques have been developed in the last 10 years as a possible alternative to conventional surgery.

METHODS

The procedure is performed under general anaesthesia, and with continuous fluoroscopic and transesophageal echocardiographic guidance. Devices of the Amplatzer family, two in particular, have achieved a large popularity in clinical practice, and are currently the devices most commonly used to close muscular and perimembranous ventricular septal defect percutaneously.

RESULTS

Data from literature show that successful closure of muscular defects is obtained in around 96% of patients, with a rate of major complication of around 2%. Pooling data from the literature shows that successful closure of perimembranous defects is also obtained in 96% of patients, again with major acute complications in around 2%. The major problem is the occurrence of complete atrioventricular block, reported in 1.7% of subjects. Acquired defects can occur as residual leaks after surgical closure, or as consequence of myocardial infarction. There are very few data concerning percutaneous closure of postoperative residual defects. As for the surgical approach, in patients with post-myocardial defects the success rate of percutaneous closure is around 88%, with a mortality of 22%.

CONCLUSIONS

Nowadays, in experienced hands, percutaneous closure is a safe and effective procedure. In selected patients, closure of congenital or acquired muscular and perimembranous ventricular septal defects can be considered a real alternative to the standard surgical approach, with the advantage of a significantly reduced rate of mortality and complications.

Transcatheter closure of high-risk muscular ventricular septal defects with the CardioSEAL occluder: Initial report from the CardioSEAL VSD Registry

OBJECTIVES

The CardioSEAL VSD registry was created to track safety of the device to close high-risk Ventricular Septal Defect (VSD).

BACKGROUND

This is the first report from the multi-centered CardioSEAL VSD registry reviewing demographics and initial results.

METHODS

Centers recruited patients with VSD who were high-risk for surgery due to medical condition or anatomic features.

RESULTS

18 centers contributed data on 55 high-risk patients who had 61 VSD-occlusion procedures, with age of range of 5 days to 65 years and using one to six devices. Implantation approach was transvenous in 48, perventricular in five, and by combined approach in two patients. Ninety-two percent of intended VSD device implants were judged successful. Twenty-two patients had single VSD closed by single device in 18 and by two devices in four patients. All patients <8 kg underwent perventricular device implantation. Thirty-three patients had multiple VSDs which were closed by a single device in 23, and multiple devices in 10. At discharge echocardiography showed total residual flow through all VSDs in which devices were used was classified as "Small" or less in 74%, "More than small" in 11%, and "Uncertain" in 15%. Eight major adverse events occurred in 5/61 cases (8% event rate), with 3/81 devices embolized (4% embolization rate), 5/81 devices surgically explanted (6% explant rate), and no deaths judged to be procedure-related.

CONCLUSION

This initial report from the multi-centered CardioSEAL VSD registry demonstrates the safety of the device to close high-risk VSDs.

Percutaneous closure of ventricular septal defects. State of the art

Ventricular septal defect (VSD) is the most common congenital heart disease. Surgery has been performed for many years and is considered to be the gold standard for the treatment of VSD. However, it is associated with morbidity and mortality. Percutaneous closure of VSDs is performed under general anesthesia and with fluoroscopic and transesophageal echocardiographic guidance. Two devices of the Amplatzer family are currently used to close percutaneously muscular and perimembranous VSD with a closure rate of 97% (incidence of major complication 2.2%) and 97.5% (major acute complications in 1.2%), respectively. Occurrence of complete atrioventricular block is reported in 1% of subjects. Acquired VSD can occur as post-surgical residual leak, as a traumatic event or as consequence of a myocardial infarction. There are few data about percutaneous closure of post-surgical residual VSD and of traumatic VSD. As for the surgical approach, in patients with post-myocardial infarction VSD success rate of percutaneous closure is around 88% with a mortality of 22%. The currently available data show that, in experienced hands, percutaneous closure is a safe and effective procedure. Device closure of muscular and perimembranous VSD is a real alternative to the standard surgical approach with the advantage of a significantly reduced rate of mortality and complications.

Device closure of muscular ventricular septal defects in infants less than one year of age using the Amplatzer devices: Feasibility and outcome

OBJECTIVES

In this study, we evaluated the feasibility, safety, and outcome of device closure of muscular ventricular septal defects (mVSD) in infants less than 1 year of age using the Amplatzer devices.

BACKGROUND

Closure of mVSDs continues to represent a surgical challenge with significant morbidity. Hence, device closure is becoming an attractive and reliable alternative. However, little is known about the feasibility of this procedure in small infants.

METHODS

Between July 1999 and September 2006, device closure of mVSD was attempted in 20 infants ranging in age from 3 days to 12 months (median +/- SD; 4.6 +/- 3.8) and in weight from 3.2 to 8.9 kg (4.6 +/- 1.9) under TEE guidance by percutaneous or hybrid (perventricular) techniques. The size of the VSD as assessed by TEE ranged from 3 to 11 mm (6.0 +/- 2.2) and the Qp:Qs ratio ranged from 0.7 to 8.8 (2.8 +/- 2.3).

RESULTS

The device was successfully placed in 19/20 infants and it ranged in size from 4 to 14 mm (8.0 +/- 2.6). It was percutaneously deployed in 11/19 and by the hybrid approach in 8/19. There were 30 devices placed in 19 infants with multiple devices placed in 5/19 infants. Fluoroscopy times ranged from 11 to 136 min (41 +/- 28) and procedure times ranged from 57 to 291 min (178 +/- 68). The success rate as defined by complete closure or a trivial shunt was 84% immediately and 100% at 1-year follow-up. Major complications occurred in 4/20 patients: wire perforation and hemopericardium (n = 1), device migration (n = 1), transient electromechanical dissociation (n = 1), and mediastinitis (n = 1). At a median follow-up of 3.8 years, all patients improved and had no hemodynamically significant VSDs. No major complications were encountered in patients with multiple devices.

CONCLUSION

In infants less than 1 year of age, percutaneous and perventricular device closure of mVSDs is technically feasible and highly effective with low morbidity. Long term safety and efficacy needs to be assessed.

Surgical repair of multiple muscular ventricular septal defects: the role of re-endocardialization strategy

OBJECTIVE

Surgical repair of multiple muscular ventricular septal defects (Swiss cheese septum) is associated with important morbidity and mortality. We sought to examine factors associated with permanent heart block, early mortality, and time-related survival. Additionally, we evaluated a new approach, transatrial re-endocardialization of interventricular septum, to mitigate risk.

METHODS

One hundred sixteen patients underwent surgery for multiple muscular ventricular septal defects (1982-2005), of whom 64 (55%) had associated cardiac anomalies. Twenty-seven consecutive patients (median age 0.54 years, range 15 days-7.2 years) underwent transatrial re-endocardialization (2002-2005). Forty-four percent had Swiss cheese septum (>4 defects). Multivariable regression analysis determined risk factors for pacemaker and survival.

RESULTS

Operative mortality for the entire cohort was 9%. Risk factors for death were double-outlet right ventricle (odds ratio 44.7, P = .003), ventriculotomy (odds ratio 6.4, P = .03), and fewer multiple muscular ventricular septal defects repaired (odds ratio 4.7/defect, P = .04). Era mortalities differed: 16% for 1982 through 1990, 13% for 1990 through 1998, and 0% for 1999 through 2005, P = .006). Fourteen patients (12%) required a pacemaker. Time-related survivals at 1 and 10 years were 90% +/- 3% and 82% +/- 5%. Risk factors for death were double-outlet right ventricle (hazard ratio 8.3, P = .02) and longer bypass (hazard ratio 1.02/min, P = .02). In 27 re-endocardialization patients, a combined closure strategy to close 184 defects were applied: transatrial re-endocardialization (median 5, range 2-21), patch (median 1, range 0-4), and device (range 0-1). Post-repair ventricular function was good in 25 of 27 patients. The median number of residual defects was 1.5 (range 0-3), and median residual jet width on color Doppler was 2.3 mm (range 0-4.2 mm). One child required a pacemaker. There were no early or late deaths.

CONCLUSIONS

Outcome of surgical repair of multiple muscular ventricular septal defects (Swiss cheese septum) has improved. Transatrial re-endocardialization strategy enables early complete or nearly complete obliteration of multiple muscular ventricular septal defects with minimal residual lesions (shunt, ventricular dysfunction). Long cardiopulmonary bypass duration is well tolerated. The incidence of permanent heart block has improved. Early echocardiographic and clinical outcomes are promising.

Ventricular Septal Defects

Ventricular septal defects are the most common congenital heart defect. They vary greatly in location, clinical presentation, associated lesions, and natural history. The present article describes the clinical aspects of ventricular septal defects and current management strategies.

Transcatheter devices used in the management of patients with congenital heart disease

The availability of transcatheter devices has revolutionized the management of patients with congenital heart and vascular disease. Many patients that were in the past exclusively treated through open heart surgical procedures can now be managed using a percutaneous approach. This article describes those devices that are, at present, most frequently used in the USA for transcatheter therapy of congenital heart disease, which have, or are about to receive, US premarket approval. It also focuses on devices for occlusion of septal defects and vascular structures, as well as endovascular stents. In addition, the most important outcome data are discussed.

Transcatheter device versus surgical closure of ventricular septal defects: A clinical decision analysis

OBJECTIVES

To compare transcatheter device versus surgical closure of ventricular septal defects (VSDs).

METHODS

A clinical decision analysis was performed using standard gamble interviews.

RESULTS

Device was initially preferred in 39 respondents (89%) and surgery in 5 (11%). The inherent difference in value between a perfect surgery and a perfect device (disutility of surgery) was equal to a mean risk of death of (1.2 +/- 2.2)%. Final values from decision analysis were initially equivalent. Values adjusted for estimated mortality, however, favored device (mean: 0.979 +/- 0.032) versus surgery (mean: 0.971 +/- 0.032), P = 0.052. When values were further adjusted for disutilities, device was significantly preferred (0.978 +/- 0.032) versus surgery (0.961 +/- 0.044), P < 0.005. Surgery would be preferred if the probability of major complications decreased below 5% or minor complications below 6%.

CONCLUSIONS

When outcomes and their values are considered in a systematic manner, transcatheter device closure of suitable VSDs is favored over surgical repair.