Transcatheter closure of apical ventricular muscular septal defect combined with arterial switch operation in a newborn infant

State of the art catheter interventions in adults with congenital heart disease

Catheter interventions in adults with congenital heart disease have rapidly advanced. Transcatheter valve repair and replacement techniques have been added to the existing spectrum of well-established procedures. This review summarizes current transcatheter management strategies for congenital cardiac anomalies seen in the adult population.

Preclinical evaluation of a new self-expanding device for closure of muscular ventricular septal defects in a pig model

OBJECTIVES

Aim of our study was the preclinical evaluation of a new self expanding device for interventional closure of muscular ventricular septal defects (mVSDs) in an acute pig model.

BACKGROUND

Devices currently in use for closure of mVSDs still have their limitations. The deployment of the disks is dependent from the expansion of the stent, which can be associated with problems for sufficient closure of the mVSDs. This was the reason for developing a modified device with only one disk

MATERIALS AND METHODS

The device was constructed in a single wire technique with a unique configured retention disk. mVSDs were created in six pigs with a specially designed punch instrument, and subsequently closed with our new device during the same session using a jugular or femoral vein approach. Potential residual shunting volumes were estimated by echocardiography and hemodynamic measurements. After closure, animals were sacrificed, and hearts were harvested for macropathologic evaluation. In two animals, MRI was performed for additional noninvasive evaluation.

RESULTS

Devices were successfully implanted in all animals with good alignment of the disk to the left ventricular septum, even if the stent was oversized. Echocardiography, hemodynamics, angiography and macropathology revealed complete closure of all mVSDs. MRI and echocardiography showed a good visibility of the device.

CONCLUSIONS

Our preclinical study shows successful closure of iatrogenic created mVSDs without residual shunting. The device is characterized by a more controlled deployment, an independent deployment of disk and waist, and a good alignment of the left ventricular disk to the muscular septum.

Retrograde approach for device closure of muscular ventricular septal defects in children and adolescents, using the Amplatzer muscular ventricular septal defect occluder

This study presents technique and initial experience of retrograde deployment of the Amplatzer muscular ventricular septal defect occluder (AmVSDo) for closure of muscular ventricular septal defects (VSDs). The conventional technique for closing muscular VSDs involves the creation of an arteriovenous guidewire circuit and use of a transvenous approach for device deployment. Seven patients aged 2.2-15 years underwent transcatheter closure of a muscular VSD using the retrograde approach without making the arteriovenous wire circuit. Mean fluoroscopy and procedural times were compared to those previously reported in publications describing the use of the antegrade approach. Unpaired Student's t-test was used to compare the two parameters in two groups. Our technique was successful in all patients reported. The mean fluoroscopy time in the retrograde versus the antegrade group was 33.8 +/- 20.9 and 41.9 +/- 6.2 minutes, respectively (not significant), and the mean procedural time in the two groups was 91.1 +/- 22.1 and 114 +/- 33.9 minutes respectively (p = 0.025). No complications were noted. We suggest that some muscular VSDs can be safely closed retrogradely without the use of an arteriovenous loop, thus reducing the radiation exposure and also the cost of the procedure. Further studies are needed to confirm this initial experience.

Transcatheter occlusion of a residual muscular ventricular septal defect using an Amplatzer duct occluder in a child with congenitally corrected transposition of the great arteries

Transcatheter occlusion has become an acceptable alternative to surgery in patients with congenital muscular and residual post-surgical ventricular septal defects (VSD). We present a case of an 11 year old male with congenitally corrected transposition of the great arteries, dextrocardia, pulmonary atresia, VSD, and advanced second degree atrioventricular block who underwent successful transcatheter occlusion of a residual post-surgical VSD with an Amplatzer duct occluder, in preparation for transvenous pacemaker implantation.

Arterial switch operation for transposition of the great arteries combined with closure of paramembranous ventricular septal defect using the Amplatzer membranous ventricular septal occluder

Ventricular septal defects (VSDs) complicate the arterial switch operation (ASO) in newborns with transposition of the great arteries because of prolonged cardiac arrest time and subsequent ventricular dysfunction. Three newborns with paramembranous VSDs were successfully treated using the newly designed Amplatzer membranous VSD occluder during the ASO. The implantation of a 4-mm asymmetric Amplatzer device in 2 patients and an 8-mm device in the third resulted in the complete occlusion of the septal defects. The cardiac arrest time for anatomic repair might be effectively reduced by this new approach in pediatric cardiac surgery.

Percutaneous closure of congenital and acquired ventricular septal defects--considerations on selection of the occlusion device

Nonsurgical closure of congenital and acquired ventricular septal defects (VSD) has become increasingly acceptable with the availability of various occlusion systems that allow percutaneous treatment of muscular and membranous defects. This study describes a series of 12 patients (0.2-74-years-old) who underwent defect closure with six different occlusion systems. Device selection according to anatomy and outcome is highlighted. Seven VSDs were located in the membranous part of the septum, five in the mid-muscular septum. Complex heart lesions were present in five postmyocardial infarction VSD in one and residual postsurgical defects in three patients. The size of the VSD ranged from 2.6 to 10 mm. The applied devices were: Amplatzer muscular VSD occluder (n=4), Amplatzer septal occluder (n=2), Amplatzer duct occluder (n=1), Amplatzer membranous VSD occluder (n=2), Nit-Occlud coil (n=2), and Cook PDA coil (n=1). The devices were implanted successfully in nine patients. There was complete VSD closure in eight patients within the first 24 hours. In one patient, a trivial residual shunt disappeared at 6 months follow-up. Because of device instability, two occluders were removed during catheterization. In two other cases, tricuspid valve tissue was entrapped in the occluder and had to be removed surgically, one of them during the consecutive Rastelli operation. Neither significant arrhythmia, nor thromboembolism or hemolysis occurred in out patients during follow-up. Transcatheter closure of VSD is an attractive alternative to surgery. In complex congenital heart disease, surgical-interventional hybrid therapy may improve morbidity and total outcome. The recently developed Amplatzer VSD devices allow closure of muscular and membranous VSDs. Implantation and short-term follow-up are superior to the formerly used devices. Long-term effects have to be evaluated in further studies.

Management of paediatric patients undergoing diagnostic and invasive cardiology procedures

Since diagnostic cardiac catheterization in children with congenital heart disease was first reported in 1947, echocardiography has been used as a non-invasive diagnostic tool in congenital heart disease, resulting in a decrease in diagnostic cardiac catheterizations. However, the total number of cardiac catheterizations remained at a steady level until the mid-1980s and has since increased progressively. This is a result of the introduction of interventional transcatheter techniques to improve or correct congenital heart malformations. Since the first description of balloon atrial septostomy, the range of indications for such techniques has steadily increased, particularly in the past 15 years. 'Deep' sedation or general anaesthesia is essential for the conduct of cardiac catheterization in children, particularly in the younger age group.

Outcomes of intraoperative device closure of muscular ventricular septal defects

BACKGROUND

The surgical management of muscular ventricular septal defects (mVSD) in the small infant is a challenge particularly when multiple and associated with complex cardiac lesions. Devices for percutaneous implantation have the advantage of ease of placement and for the double umbrella designs a wide area of coverage. We reviewed our experience and clinical outcomes of intraoperative mVSD device closure for such defects in small infants.

METHODS

Since October 1989, intraoperative VSD device closure was a component of the surgical strategy in 14 consecutive patient implants (median age, 5.5 months; range, 3 to 11 kg), whose defects were thought difficult to approach using conventional techniques. Nine patients had associated complex cardiac lesions, 10 multiple mVSDs, and 4 patients had a previous pulmonary artery banding.

RESULTS

There were 2 early deaths, 1 in a severely ill child who preoperatively had pulmonary hypertension and left ventricular failure and another in a patient with a hypoplastic left heart. Mean pulmonary to systemic flow ratio before device insertion was 3.5:1. Complete closure was achieved in 5 patients and clinically insignificant residual shunts persisted in 7. In 2 infants with significant residual lesions concomitant pulmonary artery banding was required. Postoperative mean pulmonary to systemic flow ratio was 1.7:1. In follow-up of the 12 surviving infants (mean, 41 months), 8 had complete closure and 3 persistent residual shunts. One patient with no residual shunting required heart transplantation for progressive ventricular failure 9 years after operation. All devices were well positioned on postoperative echocardiograms. There was 1 late death due to aspiration in a patient with a tiny residual shunt.

CONCLUSIONS

Infants requiring operative intervention with mVSDs are difficult to manage and have an increased mortality and morbidity. Intraoperative VSD device placement for closure of mVSDs is feasible, can avoid ventriculotomy, division of intracardiac muscle bands, and is ideally suited for the neonate or infant.