Catheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: initial clinical experience

Comparison of perventricular and percutaneous ultrasound-guided device closure of perimembranous ventricular septal defects

Background

Ultrasound-guided percutaneous device closure of perimembranous ventricular septal defects (PmVSD) is a minimally invasive recent treatment approach. Perventricular PmVSD device closure is an emerging radiation-free intervention, yet it comes with certain limitations. No studies compared both of these treatment approaches.

Methods

We performed a retrospective institutional data comparison of percutaneous (PCP Group, n = 138) and perventricular (PVP Group, n = 67) ultrasound-guided device closure procedures in 205 patients with PmVSD between March 2017 and December 2022.

Results

Patients of the PCP and PVP groups had a median age of 4.9 years (IQR, 3.1-14.0) and 5.3 years (IQR, 3.4-13.1) respectively. The median PmVSD diameter in the PCP Group was 4.0 mm (IQR, 3.3-5.3) and 5.2 mm (IQR, 4.0-7.0) in the PVP Group (p = 0.001). There was no significant difference in success rates between the PCP and PVP Groups (intention-to-treat population, 88.4% vs. 92.5%, p = 0.36; as-treated population, 88.4% vs. 89.3%, p = 0.84). 5/8 failed percutaneous cases that were shifted to the perventricular approach were successful. Compared to the PVP Group, patients of the PCP group experienced a significant decrease in ventilation time, drainage volume, and postoperative hospital stay (p < 0.001). The median follow-up period was 24 months (IQR, 6-42) for the PCP group and 61 months (IQR, 53-65) for the PVP group. The overall severe adverse event rate was 0% in the PCP group and 3.0% in the PVP group.

Conclusions

Perventricular and percutaneous ultrasound-guided device closure of PmVSD are both effective and safe treatment options. The percutaneous approach offers less trauma and faster recovery and may be the preferred approach in selected patients.

Early and mid-term outcomes of transcatheter closure of perimembranous ventricular septal defects using the Lifetech™ Konar-MF Occluder device (MFO)

BACKGROUND

Transcatheter closure of perimembranous ventricular septal defects is challenging. Double disk-designed devices have high adverse event rates; therefore, research into new devices persists. One such devise is the LifetechTM Konar-MF Occluder device (MFO), which is increasingly used. The purpose of this study is to present mid-term results of MFO for transcatheter closure of patients with perimembraneous ventricular septal defect.

PATIENTS AND METHODS

Records of the 52 patients with perimembraneous ventricular septal defect who had undergone transcatheter closure with MFO were reviewed. Demographic, echocardiographic, and procedure details were investigated. Three years follow-up results were recorded.

RESULTS

We closed the perimembraneous ventricular septal defect in 51 of 52 patients (98%). The femoral venous approach was used in 27 patients (53 %) whilst no arteriovenous loop was established in the remaining patients. No significant procedure-related complication occurred. On day 1 echocardiography, the residual ventricular septal defect rate was 31%. Mean±SD (range) follow-up duration was 36 ± 7,9 (18-54) months. In the follow-up, at 6th months, only four patients had hemodynamically insignificant residual defects. No severe dysrhythmia was detected including complete heart block. A right bundle branch block pattern was seen in one patient.

CONCLUSION

This study showed that MFO is a safe and effective device in the transcatheter treatment of perimembraneous ventricular septal defect's with mid-term follow-up.

Transfemoral Perimembranous Ventricular Septal Defect Device Closure in Infants Weighing ≤ 10 kg

Transcatheter closure of Perimembranous VSDs (PMVSD) remains challenging particularly in infants. The aim of this study is to evaluate the efficacy and safety of transfemoral PMVSD device closure in infants weighing ≤ 10 kg in a single centre. Retrospective review of departmental databases and medical charts to define patient cohort and collect demographic, procedural and follow-up data. Between July 2014 and March 2021, 16 patients underwent attempted transfemoral PMVSD device closure (12 retrograde) at a median age of 11 months (interquartile range [IQR] 9-15.5) and a median weight of 8.3 kg (IQR 7.2-9.5). All patients were either symptomatic, had progressive left heart dilation or had VSD associated valve regurgitation. Median defect size on pre-procedural transoesophageal echocardiography was 6.8 mm (IQR 6-8.5). Median device waist size was 6 mm (IQR 4.5-8). Successful device placement was achieved in 14 patients (88%). One patient developed moderate aortic and tricuspid valve regurgitation upon retrograde and antegrade device deployment, respectively, and subsequently underwent surgical closure. The second patient developed progressive aortic regurgitation (AR) 2 days post procedure, and also underwent surgical removal with no residual AR. There was no cases of device embolization and no femoral arterial compromise. On median follow-up of 40.5 months (IQR 25-64), none of the patients developed complete heart block. Three patients (18.75%) had small residual shunts at latest follow-up which have not required any further intervention. Device closure of PMVSD's in children weighing ≤ 10 kg is feasible and safe with good procedural success rates. Use of both the antegrade and retrograde approaches may be necessary depending on anatomical variances.

Percutaneous Transcatheter Closure of Congenital Ventricular Septal Defects

Ventricular septal defects (VSDs) are the most common kind of congenital heart disease and, if indicated, surgical closure has been accepted as a gold-standard treatment. However, as less-invasive methods are preferred, percutaneous device closure has been developed. After the first VSD closure was performed percutaneously by Lock in 1988, both techniques and devices have developed consistently. A perventricular approach for closure of muscular VSD in small patients and the closure of perimembranous VSD using off-label devices are key remarkable developments. Even though the Amplatzer membranous VSD occluder (Abbott) could not be approved for use due to the high complete atrioventricular conduction block rate, other new devices have shown good results for closure of perimembranous VSDs. However, the transcatheter technique is slightly complicated to perform, and concerns about conduction problems after VSD closure with devices remain. There have been a few reports demonstrating successful closure of subarterial-type VSDs with Amplatzer devices, but long-term issues involving aortic valve damage have not been explored yet. In conclusion, transcatheter VSD closure should be accepted as being as effective and safe as surgery but should only be performed by experienced persons and in specialized institutes because the procedure is complex and requires different techniques. To avoid serious complications, identifying appropriate patient candidates for device closure before the procedure is very important.

Peratrial device closure of perimembranous ventricular septal defects via a small right subaxillary incision: Midterm results in patients <12 months of age

BACKGROUND

Both percutaneous and perventricular device closures of perimembranous ventricular septal defects (Pm-VSDs) are alternatives to surgical procedures，but they all present certain drawbacks.

OBJECTIVE

To report our clinical experiences and midterm follow-up results of minimally invasive peratrial device closure of Pm-VSDs under the guidance of transesophageal echocardiography(TEE) in patients <12 months of age.

METHODS

Between January 2015 and December 2020，268 patients <12 months of age with Pm-VSDs underwent peratrial device closure in our institute. The procedure was performed under TEE guidance via a small right subaxillary incision. The delivery pathways is established by manipulating the hollow probe, and then the device is installed.

RESULTS

A total of 263 cases (98.1%) underwent successful closure, whereas five cases failed and were converted to cardiopulmonary bypass operation via the original incision during the procedure. The mean age was 9.5 ± 2.0 months and the mean body weight was 8.8 ± 1.4 kg. The mean diameter of the VSD was 4.4 ± 0.5 mm. One patient (0.4%) underwent a second thoracotomy for postoperative intercostal hemorrhage on the second day after surgery. The mean diameter of the occluder size was 5.5 ± 0.6 mm. During the follow-up (4.3 ± 1.4 y), there was no mortality, no new aortic valve regurgitation and atrioventricular block.

CONCLUSION

Peratrial device closure of Pm-VSDs via the right subaxillary route under TEE guidance is safe and effective at midterm follow-up, confirming this is an valuable alternative method for patients <12 months of age.

Long-Term Follow-up of Transcatheter Ventricular Septal Defect Closure in Children, and Comparison of Single-Hole Versus Multi-holes Ventricular Septal Defects

Background: Evaluation of complications after transcatheter ventricular septal defect (VSD) closure in long-term follow-up and large samples of children is limited. Objectives: We compared the residual shunt after transcatheter closure in VSDs with a single hole and multiple holes, a new task that has not been done so far. Methods: This retrospective study included all patients who underwent transcatheter device closure for VSD in a tertiary cardiovascular center from 2009 to 2020. Follow-up evaluation using transthoracic echocardiography (TTE) and electrocardiogram (ECG) was performed at 1, 6, 12 months, and annually after the procedure. Results: A total of 409 patients underwent transcatheter VSD closure. The mean age was 7 years (2 - 15 years), and the median follow-up duration was 48 months (1 - 10 years). The number of patients with a singular VSD was 259 (63.4%), and those with multiple exit holes were 150 (36.6%). The incidence of a residual shunt immediately after implantation was significantly higher in VSDs with multiple holes than those with a single hole (P = 0.008). During the follow-up, the residual shunts decreased in the group of VSDs with a single hole. Forty-five patients (11%) and 16 patients (4%) had a new-onset of mild and moderate tricuspid regurgitation (TR), respectively, and it decreased dramatically over time. Only 1 patient showed a new-onset mild aortic regurgitation (AR). The most crucial complication shown in 2 patients was a persistent complete heart block. Conclusions: Ventricular septal defects with multiple exit holes are a risk factor for a residual shunt. After transcatheter VSD closure, the residual shunt in patients with a multiple-hole VSD was significantly higher (P = 0.008). Although TR may increase during the procedure, it decreases dramatically over time. Interestingly, patients who had pre-procedure tricuspid or aortic regurgitation disappeared after 2 years of the procedure. The most important complication was a complete heart block in 2 patients.

Percutaneous closure of ventricular septal defect using LifeTechTM Konar-MF VSD Occluder: initial and short-term multi-institutional results

BACKGROUND

Transcatheter ventricular septal defect closure remains a complex procedure with potential complications like complete heart block and aortic regurgitation. The ideal device design for such intervention is still evolving.

AIM

To assess the safety, efficacy, and short-term outcome of ventricular septal defect closure using LifeTechTM multifunctional (KONAR-MFTM) VSD Occluder.

PATIENTS AND METHODS

In a multicenre study, 44 patients with haemodynamically significant, restrictive ventricular septal defects underwent closure with the KONAR-MFTM device from April, 2019 to March, 2020. Clinical, echocardiographic, and angiographic data were collected and reviewed. Patients were followed up at 1, 3, 6, and 12 months.

RESULTS

The median age and weight were 8 (1.7-36) years and 20 (11-79) kg. Of 44 patients, 8 (18%) had a high muscular and 36 (82%) had a perimembranous defect, of which 6 had mild prolapse of the right coronary cusp. The median ventricular septal defect size was 8.8 (3.9-13.4) mm. A retrograde approach was adopted in 39 (88.6%) patients. Nine patients (20.5%) had a small residual leak and there was a slight increase in aortic regurgitation in one patient. One device, which embolised to pulmonary artery was retrieved, and the defect was closed with a larger device. At a median follow-up of 13 (5-18) months, the residual leak persisted in 1 (2.3%) patient. Mild aortic regurgitation in one patient remained unchanged. There were no major complications.

CONCLUSION

Percutaneous closure of ventricular septal defect using KONAR-MFTM device is safe and effective in short and midterm follow-up including selected patients with perimembranous defect and mild prolapse of the right coronary cusp.

Finite Element Analysis and Bench Testing of Ventricular Septal Defect Occluder

Complications after transcatheter closure of the ventricular septal defect (VSD) is significantly associated with the mechanical behaviour of the VSD occluder. This study aims to investigate the effect of structural parameters of the VSD occluder. A mechanical model of the VSD occluder was constructed by theoretical modelling. The mechanical properties of the VSD occluders with different braiding angles (30°, 45°, 60°), materials (nitinol (NiTi), polydioxanone (PDO)) and waist-heights (3 mm, 4 mm) were analysed and validated by bench tests. For the 30°NiTi, 45°NiTi, 60°NiTi and 45°PDO occluders, the bending angles at the waist under 1 mm radial shrinkage were 112°, 121°, 155° and 155°, respectively. And the maximum principal strains at the waist were 16.62%, 8.19%, 1.20%, and 0.66%, respectively. The maximum radial deformations with 0.5 rad axial bending at the waist were 1.73, 1.44, 0.41 and 1.68 mm, respectively. When the occluders were implanted into VSD with the mean thickness of 3.5 mm, high stress appeared at the margin and the contact area, and the area with the 3-mm-occluder was much larger. In conclusion, the 60°NiTi occluder showed better ability to fit the deformation of the defect than the other NiTi occluders, and the 45°PDO occluder performed better under compression conditions but poorly under bending conditions than the 45°NiTi occluder. The choice of the appropriate waist-height is beneficial to eliminate associative complication by reducing the contact stress.

Transcatheter Closure of Perimembranous Ventricular Septal Defect Using the Lifetech Konar-Multi Functional Occluder: Early to Midterm Results of the Indonesian Multicenter Study

Background:

The alternative device to close perimembranous ventricular septal defect (pmVSD) has been searched for better result, less complications and applicable for infants. However, the ideal device is still unavailable. We aimed to evaluate the effectiveness and outcome of transcatheter pmVSD closure using the KONAR-multi functional occluder (MFO).

Methods:

Clinical, procedural, follow-up data of pmVSD patients with symptom of heart failure or evidence of significant left to right shunt, growth failure, recurrent respiratory tract infection, and history of endocarditis who underwent transcatheter closure using the MFO were prospectively evaluated.

Results:

Between January 2016 and December 2017, there were complete records of 132 pmVSD children closed using MFO from eleven centers in Indonesia. The median of age was 4.5 (0.3–17.4) years; weight 14.8 (3.5–57) kg, defect size at the smallest part 3.4 (1.0–8.1) mm, flow ratio 1.6 (1.3–4.9), mean pulmonary artery pressure 18 (7–79) mmHg, fluoroscopy time 18 (3.8–91) and procedural time 75 (26–290) minutes. A retrograde approach was done in 41 (31%) patients. Procedures succeeded in first attempt in 126 (95.4%), failed in three and migration in three patients. Six of eight infants with congestive heart failure were closed successfully. Of 126 patients with successful VSD closure, 12 months follow-up were completed in all patients. The rate of complete occlusion at 1 month, 3 months, 6 months and 12 months after intervention were 95.2%, 97.6%, 99.2%, and 99.2%, respectively. New-onset aortic regurgitation and moderate tricuspid regurgitation developed only in five and three patients. Neither complete atrioventricular block, nor other complications occurred.

Conclusion:

Transcatheter closure of pmVSD using the MFO is safe, effective, and feasible in infants and children.

Risk factors for atrioventricular block after occlusion for perimembranous ventricular septal defect

BACKGROUND

The risk factors for complete atrioventricular block (CAVB) after device closure of perimembranous ventricular septal defect (pmVSD) remain unclear.

OBJECTIVE

The purpose of this study was to analyze the incidence and risk factors for CAVB after device closure for pmVSD.

METHODS

We reviewed 1884 patients with pmVSD who had undergone successful device occlusion between June 2005 and January 2020. Permanent CAVB was defined as CAVB requiring implantation of a permanent pacemaker (PPM) or extraction of the occluder.

RESULTS

In total, 14 patients (0.7%) developed permanent CAVB. Of these patients, 10 (0.5%) required PPM implantation. Four permanent CAVB occurred within 7 days after the procedure (acute), 2 between 7 and 30 days (subacute), 3 between 30 days and 1 year (late), and 5 more than 1 year (very late). None of the subacute, late, and very late CAVB recovered normal conduction with medication and eventually required device removal or PPM implantation. Four patients with acute CAVB and 1 with subacute CAVB underwent device removal, and 4 (80%) recovered normal conduction. Multivariate regression revealed that the ratio of device to defect size was the only independent risk factor for permanent CAVB (odds ratio 3.027; 95% confidence interval 1.476-6.209; P = .003).

CONCLUSION

The incidences of permanent CAVB after occlusion for pmVSD and PPM implantation were 0.7% and 0.5%, respectively. The ratio of device to defect size was the only independent risk factor for permanent CAVB. Device removal is an effective therapeutic modality for recovering normal conduction in acute and subacute CAVB patients.

The Long-Term Change of Arrhythmias after Transcatheter Closure of Perimembranous Ventricular Septal Defects

OBJECTIVES

To observe and analyze the long-term change of different types of arrhythmias after transcatheter closure of perimembranous ventricular septal defect (pmVSD).

METHODS

We retrospectively collected the data of patients who underwent pmVSD closure in our institution from March 2002 to December 2010.

RESULTS

One hundred thirty-nine patients met the inclusion criteria, of which 265 (25.5%) had early arrhythmia. They were classified into two categories: conduction abnormality (191/1039; 18.4%) and origin abnormality (94/1039; 9.0%), including 20 patients with both types of arrhythmias. The median follow-up time was 84.5 months, and 103 patients (103/191; 53.9%) with early conduction block got permanent arrhythmias, while only three patients (3/94; 3.2%) with early anomalous origin arrhythmias still had an abnormal electrocardiogram. Serious arrhythmias (28/1039; 2.7%), including II° atrioventricular block (AVB), III° AVB, and complete left bundle branch block (CLBBB), can appear immediately in the early postoperative period (21 patients) or in the late outset (seven patients) after several months or even years (6 months to 8.3 years). Twenty patients (20/21; 95.2%) with serious arrhythmia in the early postoperative period improved after early treatment, but six patients relapsed or worsened during follow-up. At the endpoint, severe arrhythmia persisted in 13 patients, of which four patients got permanent pacemaker implanted, and one patient with recurrent CLBBB died from heart failure.

CONCLUSIONS

The probability of delayed CAVB or bundle branch block after VSD closure is low but often occurs several years after surgery. Therefore, long-term ECG follow-up should last for several years or even decades. Serious arrhythmias that appear early after transcatheter pmVSD closure may impose a risk of recurrence although they have been cured already. Close attention should be paid to the changes of cardiac function in patients with CLBBB after VSD closure, and the severity of such arrhythmia should be taken seriously and reexamined.

Update on shunt closure in neonates and infants

Introduction: Cardiac defects that result in shunting are the most common types of congenital heart anomalies. Although these lesions can be simple, they can cause significant hemodynamic changes and can be challenging to manage in neonates and infants. Over the recent decades, the development of new transcatheter techniques and devices has made it safe and feasible to manage such defects when indicated, even in the smallest of patients. Understanding these interventional procedures is essential in order to manage those patients.Areas covered: In this article, we review the techniques and experience for closure of atrial septal defects, ventricular septal defects, patent ductus aarteriosus,as well as coronary arteriovenous malformations and fistulas in neonates and infants. Literature review of PubMed articles was performed through January 2021, with focus on the latest data and results of the usage of interventional techniques in treating these lesions specifically in this age-group.Expert opinion: Significant shunting lesions can be particularly challenging to manage in neonates and infants. Newer lower profile devices will likely continue to be developed in the future, allowing their use for transcatheter interventions in even smaller patients and those with more complex anatomy.

Transthoracic echocardiography monitoring during atrial septal defect and ventricular septal defect device closures using a three-dimensional printed transducer holder

Transthoracic echocardiography (TTE) is noninvasive but can only be performed intermittently during fluoroscopy. In a prior study, we created a transducer holder device to allow for hemodynamic monitoring in the intensive care unit. The current study is the first instance of the use of a three-dimensional (3D)-printed TTE transducer holder, which is easily customized and personalized to a previous transducer holder at relatively low cost and short production time, to enable continuous TTE monitoring during device closure of an atrial septal defect (ASD) and ventricular septal defect (VSD). There were 14 ASD patients and 9 VSD patients scheduled to undergo device closure. The study's real-time TTE monitoring was performed by using a 3D-printed transducer holder over the course of the entire implantation procedure. There were 23 patients who successfully underwent septal closures using the 3D-printed holder that enabled real-time images over the entire procedure. The median duration for real-time TTE guidance was 15 minutes for the ASD and 36 minutes for the VSD and the median fluoroscopy time was 11 minutes for the ASD and 30 minutes for the VSD. One migrating VSD occluder and one case of aortic regurgitation after occluder deployment were noted by real-time TTE monitoring during the procedure. Our novel 3D-printed transducer holder can provide transesophageal echocardiography-like real-time imaging during device closure of an ASD and a VSD and may become a new alternative method in ASD and VSD closures. It can also prevent radiation exposure for the intervention team who would otherwise need to perform TTE during live fluoroscopy.

Transthoracic echocardiography monitoring during ASD closure using an artificial hand system

Aim

Continuous real-time echocardiographic monitoring is essential for guidance during ASD closure. However, transthoracic echocardiography (TTE) can only be implemented intermittently during fluoroscopy. We evaluate a novel approach to provide real-time imaging during the entire procedure.

Finding

We developed a custom-made TTE monitoring apparatus using artificial hand (AH-TTE) that enables real-time TTE images during atrial septal defect (ASD) closure. Thirty-two patients underwent successful device implantation using AH-TTE monitoring without complications. The median duration for real-time AH-TTE monitoring was 22 min and the median fluoroscopy time was 7.2 min. One case of pericardial effusion and one of transient bradycardia event due to air embolism was detected. All patients had uneventful recoveries.

Conclusions

Our simple and novel monitoring technique with AH-TTE provides TEE-like monitoring and may be a new alternative method for ASD closure. It gives real-time stable TTE images and minimizes radiation exposure for the interventional team during fluoroscopy.

Transcatheter Closure of Perimembranous Ventricular Septal Defects Using Different Generations of Amplatzer Devices: Multicenter Experience

Objectives

To demonstrate safety and efficacy of using different generations of softer Amplatzer™ devices for ventricular septal defect (VSD) closure to avoid serious complications at follow-up.

Background

Transcatheter closure of perimembranous ventricular septal defects (PmVSD) is a well-established procedure; however, it is associated with unacceptable incidence of complete heart block. Great advantages have been achieved by using softer devices for VSD transcatheter closure. The first and second generation of Amplatzer™ occluders (AVP II, ADO, and ADO II) seem to offer a safe and attractive alternative for this procedure. These devices can be delivered using either an arterial (retrograde) or venous (prograde) approach.

Methods and Results

Patients with congenital PmVSD who underwent transcatheter closure using ADO, ADO II, and AVP II devices were included. Primary end point was to determine efficacy and safety of these generations of devices and to determine the incidence of complications at follow-up (complete AV block and aortic/tricuspid/mitral regurgitation). One hundred and nineteen patients underwent VSD closure at a median age of 5 years (8 months–54 years). During the catheterization, there were only minor complications and at follow-up of 36 ± 25.7 months (up to 99 months), the closure rate was high of 98.3% and freedom from AV block was 100%.

Conclusions

The use of softer Amplatzer™ devices is a good alternative to achieve PmVSD closure safely with no risk of AVB during the procedure or at midterm follow-up.

Transcatheter Device Closure of Perimembranous Ventricular Septal Defect in Pediatric Patients: Long-Term Outcomes

Aims

The aim of this study is to evaluate the safety and efficacy of transcatheter device closure of perimembranous ventricular septal defects in pediatric patients at long-term follow-up.

Materials and Methods

We prospectively studied 376 patients with perimembranous VSDs between September 2008 and December 2015 who underwent percutaneous closure at our center. Transthoracic echocardiography (TTE) and electrocardiogram were done before and after the procedure in all the patients. All patients were subjected to follow-up evaluation at 1, 3, 6, 12 months, and annually thereafter with TTE and electrocardiogram.

Results

A total of 376 patients (210 males and 166 females) underwent transcatheter closure of perimembranous VSD. Mean age of patients was 8.67 ± 3.02 (range 3-18 years) and mean weight was 21.15 ± 8.31 (range 8-65 kg). The procedure was carried out successfully in 98.93% of patients with no reported mortality. Rhythm disturbances occurred in 8.5% of patients after the procedure which included three cases of complete atrioventricular block.

Conclusion

This study shows that in experienced hands transcatheter closure of perimembrnous VSD is safe and effective at long-term follow-up. With minimal morbidity and no mortality, the transcatheter is an effective alternative to surgical closure in selected patients.

An innovative occluder for cardiac defect: 3D printing and a biocompatibility research based on self-developed bioabsorbable material-LA-GA-TMC

This study adopted the latest self-developed bioabsorbable material lactide-glycolide-1,3-trimethylene carbonate (LA-GA-TMC) and applied the three-dimensional (3D) printing technique to manufacture the occluder for cardiac septal defects, so as to realize the individualized treatment of cardiac septal defects. At the same time, its biosafety was evaluated, with an aim to establish foundation for futural large-scale animal experiment and clinical trial. The traditional "one-pot synthesis" was modified, and the "two-step synthesis method" was utilized to synthesize the LA-GA-TMC terpolymer at the lactide: glycolide: trimethylene carbonate ratio of 6:1:1.7. Afterward, the synthesized terpolymer was used as the raw material to fabricate the occluder model via using 3D printing technique. Then, its biocompatibility was comprehensively evaluated through cytocompatibility, blood compatibility, and histocompatibility. The occluder made from LA-GA-TMC 3D printing had favorable ductility and recoverability; besides, it possessed the temperature-control feature, and the relative cell proliferation rates in extract liquids at various concentrations were all >70%, suggesting that it had favorable cytocompatibility. Moreover, hemolytic experiment revealed that its hemolytic rate was <5%, dynamic blood coagulation experiment demonstrated that the sample material moderately activated the blood coagulation, and the above findings suggested that it had good blood compatibility. In addition, implanting experiment in vivo revealed that its histocompatibility was superior to the traditional nitinol and the emerging poly-l-lactic acid. It is completely feasible to manufacture the cardiac septal defects occluder based on the novel absorbable material LA-GA-TMC, which has favorable biocompatibility, through 3D printing technique and it possesses broad prospects in large-scale animal experiment and clinical trial.

Using the Arm for Structural Interventions: Case Selection or Wave of the Future

The transradial approach has emerged as the preferred alternative to the traditional transfemoral approach owing to the increased evidence of its safety and efficacy. The field of structural heart disease is rapidly evolving; however, periprocedural complications related to access site remain a major determinant of morbidity and mortality. The transradial approach as primary or secondary access site in structural heart interventions like transcatheter aortic valve replacement, balloon aortic valvuloplasty, alternative access, alcohol septal ablations, paravalvular leak, valve snaring, coronary protection, and ventricular septal defect is feasible, safe, with lower vascular complications and high procedural success.

Beyond atrial septal defect closure, it is time to start seriously considering closing ventricular septal defects with devices

PURPOSE OF REVIEW

The purpose of this review is to discuss the history and current state of transcutaneous device closure of ventricular septal defects.

RECENT FINDINGS

Newer devices and techniques have expanded the role of transcutaneous device closure of ventricular septal defects. Device closure of ventricular septal defects is a mainstay of therapy in many parts of the world. Device closure in smaller infants has relatively higher risks than larger infants and older children. The potential for the development of complete heart block remains a concern with this procedure.

SUMMARY

Transcutaneous device closure of ventricular septal defects is a safe alternative to surgical repair in many patients.

Comparison of transcatheter versus surgical closure of perimembranous ventricular septal defect in pediatric patients: A systematic review and meta-analysis

OBJECTIVE

Perimembranous ventricular septal defect (pmVSD) is a common congenital heart disease (CHD) usually treated with either catheter or surgical closure. Superiority of one procedure over the other in children is still a matter of debate. We performed this meta-analysis to compare the clinical outcomes and cost of transcatheter and surgical closure of pmVSD in children.

MATERIALS AND METHODS

We searched seven databases (MEDLINE, PubMed, EMBASE, Google Scholar, CENTRAL, CINHAL, and Cochrane library) and literature references for articles published in the past 10 years (between January 2008 and January 2018) comparing closure of pmVSD by both procedures in children. The outcomes of interest were success rate, residual shunt, need for blood transfusion, complications especially complete atrioventricular block, length of hospital stay, and cost.

RESULTS

A total of 1750 articles were identified. However, only five studies fulfilled the inclusion criteria. As regards success rate, no significant difference was found between surgical and catheter closure. Residual shunt was significantly lower in catheter closure than surgical closure [risk ratio (RR) = 0.44; 95% confidence interval (CI), 0.23-0.83, p = 0.01). The need for blood transfusion and the length of hospital stay were significantly lower in the catheter closure compared to surgical closure (RR = 0.02; 95% CI, 0.01-0.08; p < 0.00001), (RR = -4.81; 95% CI, -7.76 to -1.86; p = 0.001), respectively. However, overall complications, complete atrioventricular block, and the cost were comparable in both procedures.

CONCLUSION

Transcatheter closure of pmVSD in children was as effective as surgical closure with a lower residual shunt and need for blood transfusion, and shorter hospital stay.

Transcatheter closure of doubly committed subarterial ventricular septal defects with the Amplatzer ductal occluder: initial experience

BACKGROUND

There is limited experience about transcatheter closure of doubly committed subarterial ventricular septal defects with Amplatzer ductal occluder.

METHODS

Between March, 2015 and July, 2017, a total of 22 patients with doubly committed subarterial ventricular septal defects received transcatheter closure using Amplatzer ductal occluder and underwent clinical follow-up for at least 6 months.

RESULTS

Device implantation was finally successful in 21 (95.4%) patients despite failed occlusion in one patient and intra-procedural replacement of unsuitable occluders in four (19.0%) patients. In mean 12.3 months of follow-up, there were no major complications (death, aortic valve or sinus rupture, device dislocation or embolisation, grade 2 new-onset aortic regurgitation, etc.), resulting in clinical occlusion success of 95.4%. Mechanical haemolysis occurred in one patient and resolved with medication. Residual shunt was observed in 11 (52.4%) patients (9 mild, 2 moderate-severe) post-procedurally, 14 (66.7%) patients (12 mild, 2 moderate-severe) in hospital stay, and 2 (9.5%) patients (2 mild, 0 moderate-severe) at the last follow-up. Device-induced new-onset aortic regurgitation was found in nine (42.8%) patients (9 mild, 0 moderate-severe) post-procedurally and in hospital stay, which was resolved in two (9.5%) patients and unchanged in seven (33.3%) patients at the last follow-up. Another four (19.0%) patients newly developed mild aortic regurgitation during follow-up.

CONCLUSIONS

Transcatheter closure of doubly committed subarterial ventricular septal defects with Amplatzer ductal occluder is technically feasible in the selected patients. However, further study is needed to confirm its long-term clinical outcomes.

Percutaneous closure of perimembranous ventricular septal defects utilizing almost ideal Amplatzer Duct Occluder II: Why limitation in sizes?

AIM

The purpose of this study is to describe the special aspects of perimembranous ventricular septal defects (pmVSD) closure by utilizing Amplatzer Duct Occluder II (ADO II) devices with a rational request for bigger ADO-II sizes, based on our experience in transcatheter device closure of pmVSD.

METHODS AND RESULTS

At our institution, placement of an ADO II device was used in 15 patients with pmVSD; the patients' age ranged between 6 months and 20 years. The indications for closure were CHF (n = 4), hemodynamically significant shunt (n = 7), tricuspid regurgitation (n = 3), and high risk for infective endocarditis (n = 2), respectively. The location of the VSD was infracristal in 13 patients, supracristal in 1, and a postsurgical Gerbode VSD in another one. Implantation of the device was successfully performed without embolization, any evidence of an AV block, or other conductance abnormalities during implantation and follow-up in the mean of 2.5 years (range 2 months-6.5 years).

CONCLUSIONS

Transcatheter closure of a pmVSD with ADO II is feasible in all pediatric and young adult age groups, by considering the device diameter limitations. The off-label use of ADO II implantation seems to be safe for VSDs closure up to 6 mm of size and feasible for various locations including unusual morphology such as postsurgical Gerbode defect.

Adult Congenital Interventions in Heart Failure

Congenital heart disease (CHD) is the most common birth defect, occurring in approximately 0.8% to 1.0% of neonates. Advances in medical and surgical therapies for children with CHD have resulted in a growing population of patients reaching adulthood, with survival rates exceeding 85%. Many of these patients, especially if managed inappropriately, face the prospect of future complications including heart failure and premature death. For adults with uncorrected or previously palliated CHD, percutaneous therapies have become the primary treatment for many forms of CHD. In this article, we discuss the role of transcatheter interventions in the treatment of adults with CHD.

Transcatheter Closure of Perimembranous Ventricular Septal Defects in Children using a Wire-Drifting Technique

OBJECTIVE

Explore the feasibility and safety of transcatheter closure of perimembranous ventricular septal defects using a wire-drifting technique (WT) in children.

METHODS

We retrospectively analyzed 121 pediatric patients diagnosed with perimembranous ventricular septal defects who underwent interventional treatment at the First Affiliated Hospital of Xi'an Jiaotong University from Dec 2011 to Dec 2014. Based on the method used for arteriovenous loop establishment during the procedure, the patients were divided into a conventional technique (CT) group and a WT group.

RESULTS

In total, 51 of the 53 patients (96.2%) in the CT group and 66 of the 68 patients (97.1%) in the WT group achieved procedural success, with no significant difference between the two groups (p>0.05). The CT group showed a nonsignificantly higher one-time success rate of arteriovenous loop establishment (94.3% vs. 91.2%, p>0.05). The procedure time was 46.0 (14.0) min and 46.5 (10.0) min in the CT and WT groups, respectively. The CT procedure was discontinued in the 2 cases (3.8%) of intraprocedural atrioventricular block in the CT group. In the one case (1.9%) of postprocedural atrioventricular block in the CT group, a permanent pacemaker was implanted to resolve third-degree atrioventricular block three months after the procedure. In the WT group, no cases of intraprocedural atrioventricular block occurred, and one case (1.5%) of postprocedural atrioventricular block occurred. In this case, intravenous dexamethasone injection for three days returned the sinus rhythm to normal. Aggravated mild to moderate tricuspid regurgitation was observed in 2 patients (3.8%) in the CT group during the 2-year follow-up period; aggravated tricuspid regurgitation was not observed in the WT group. During the 2-year follow-up period, there was no evidence of residual shunting in either group.

CONCLUSION

Transcatheter closure of perimembranous ventricular septal defects with the WT is safe and effective in children.

Ventricular Septal Defect Closure Devices, Techniques, and Outcomes

Transcatheter closure of ventricular septal defects (VSDs) was first documented in 1988. The early studies of VSD closure were successful but there were high complication rates, particularly early and late-onset complete heart block. However, the development and use of new vascular occlusion devices in an off-label fashion has improved the range of patients who can be treated and reduced the complication rates. In particular, the rate of complete heart block documented in contemporary studies of VSD closure has fallen to levels at or below those documented in the surgical VSD closure literature.

Comparison of transcatheter closure, mini-invasive closure, and open-heart surgical repair for treatment of perimembranous ventricular septal defects in children: A PRISMA-compliant network meta-analysis of randomized and observational studies

OBJECTIVE

Our study was aimed to comprehensively compare the relative efficacy, safety, and the cost of transcatheter closure, mini-invasive closure, and open-heart surgical repair to treat perimembranous ventricular septal defects (pmVSDs) in children using network meta-analysis method.

METHODS

Five databases were systematically searched including Chinese Biomedical Literature Database, China National Knowledge Infrastructure, PubMed, EMBASE.com, and the Cochrane Central Register of Controlled Trials from the starting date of each database to February 2017. Tools for assessing the risk of bias in nonrandomized studies of interventions (ROBINS-I) were used to evaluate the risk of bias in observational studies and Cochrane Handbook version 5.1.0 was used for randomized controlled trials (RCTs). Data were analyzed using R-3.4.0 software and Review Manager 5.2.

RESULTS

Three RCTs and 24 observational studies were included in our study. Network meta-analysis result demonstrated that transcatheter closure was the most effective treatment in terms of operative time [standardized mean difference (SMD) = -2.02, 95% confidence interval (CI): -3.92 to -0.12], major complications [odds ratio (OR) = 0.52, 95% CI = 0.30-0.91], ICU stay (SMD = -1.11, 95% CI = -2.13 to -0.08), and hospital stay (SMD = -1.81, 95% CI = -2.24 to -1.39). However, open-heart surgical repair showed a higher success rate of the procedure than transcatheter closure (OR = 0.36, 95% CI = 0.17-0.77).Statistical analysis result demonstrated that transcatheter closure had the best potential to lessen major complications, ICU stay, hospital stay, operative time, and significant residual shunt.

CONCLUSIONS

Transcatheter closure has more benefit than mini-invasive closure and open-heart surgical repair to treat pmVSDs.

Early Experiences Using Cocoon Occluders for Closure of a Ventricular Septal Defect

BACKGROUND

Transcatheter device closure of ventricular septal defect (VSD) has become an attractive alternative to surgery. We report here on our early experiences of transcatheter closure of VSD using Cocoon devices, which are now available in Korea.

METHODS

We reviewed the medical records and angiographic images of 13 patients who underwent transcatheter closure of VSD with a Cocoon occluder at Samsung Medical Center. The median patient age was 5.8 years, and the median patient weight was 20.3 kg.

RESULTS

The device was successfully implanted in all patients. The follow-up period was 10 ± 6 months, and no mortality was observed. An immediate residual leak on the next day was detected in 7 patients (including 4 with perimembranous VSD). However, 6 months later, a residual leak was observed only in 2 patients with perimembranous VSD and 1 patient with muscular VSD. Early conduction abnormalities were observed in 3 patients, all of whom had perimembranous VSD, but no significant complete atrioventricular block was observed. One patient experienced newly developed significant aortic regurgitation that decreased spontaneously but still existed at the 6 month follow-up. No hemolysis or embolization was noted on the next day or during the follow-up period.

CONCLUSIONS

Cocoon devices can be used safely and effectively for VSD closure. However, residual leaks and conduction abnormalities may occur early after implantation, especially in patients with perimembranous VSD. Although normal conduction was recovered, long-term evaluation remains essential.

Recent advances in managing septal defects: ventricular septal defects and atrioventricular septal defects

This review discusses the management of ventricular septal defects (VSDs) and atrioventricular septal defects (AVSDs). There are several types of VSDs: perimembranous, supracristal, atrioventricular septal, and muscular. The indications for closure are moderate to large VSDs with enlarged left atrium and left ventricle or elevated pulmonary artery pressure (or both) and a pulmonary-to-systemic flow ratio greater than 2:1. Surgical closure is recommended for large perimembranous VSDs, supracristal VSDs, and VSDs with aortic valve prolapse. Large muscular VSDs may be closed by percutaneous techniques. A large number of devices have been used in the past for VSD occlusion, but currently Amplatzer Muscular VSD Occluder is the only device approved by the US Food and Drug Administration for clinical use. A hybrid approach may be used for large muscular VSDs in small babies. Timely intervention to prevent pulmonary vascular obstructive disease (PVOD) is germane in the management of these babies. There are several types of AVSDs: partial, transitional, intermediate, and complete. Complete AVSDs are also classified as balanced and unbalanced. All intermediate and complete balanced AVSDs require surgical correction, and early repair is needed to prevent the onset of PVOD. Surgical correction with closure of atrial septal defect and VSD, along with repair and reconstruction of atrioventricular valves, is recommended. Palliative pulmonary artery banding may be considered in babies weighing less than 5 kg and those with significant co-morbidities. The management of unbalanced AVSDs is more complex, and staged single-ventricle palliation is the common management strategy. However, recent data suggest that achieving two-ventricle repair may be a better option in patients with suitable anatomy, particularly in patients in whom outcomes of single-ventricle palliation are less than optimal. The majority of treatment modes in the management of VSDs and AVSDs are safe and effective and prevent the development of PVOD and cardiac dysfunction.

Tricuspid stenosis: A rare and potential complication of ventricular septal occluder device

Asymmetrical septal occluder device (ASOD) has made percutaneous closure of ventricular septal defect an easy and effective management option. Although there are reports of aortic and tricuspid valvular regurgitation after deployment of ASOD, only few cases of tricuspid stenosis (TS) has been reported so far in the literature. We report a case of malaligned ASOD that occurred after successful device closure resulting in TS along with mild tricuspid and aortic regurgitation requiring surgical retrieval. Transesophageal echocardiography played crucial role in detecting the cause of tricuspid valve dysfunction besides providing continuous monitoring during the procedure. We intend to emphasize the need of echocardiographic evaluation of the tricuspid valvular apparatus and aortic valve during and after the device deployment even after the successful device closure to prevent this rare complication.

Anatomic and surgical factors affecting the switch from minimally invasive transthoracic occlusion to open surgery during ventricular septal defect repair

Background

This study aimed to investigate the specific causes for switching patients from minimally invasive transthoracic occlusion to surgical repair under cardiopulmonary bypass (CPB). By retrospectively analyzing 340 cases, we sought to provide the clinical reference for improving the success rate of minimally invasive transthoracic device closure of ventricular septal defect (VSD).

Methods

Among the 340 patients who underwent transthoracic closure of VSDs in the past 3 years at our hospital, 26 patients needed to be switched to surgical repair under CPB due to failure of transthoracic closure. We investigated the causes by retrospectively analyzing the findings from preoperative transthoracic echocardiography (TTE), intraoperative transesophageal echocardiography (TEE) and surgical exploration.

Results

Among the 340 patients who underwent transthoracic closure of VSDs, 26 patients (7.65%) were switched to surgical repair under CPB, which included 11 cases of membranous aneurysm (13.10%), 13 cases of perimembranous type (6.22%) and 2 cases of intracristal type (5.00%) according to their anatomic classifications. Among the 186 patients who underwent transthoracic closure during the first 17 months, 20 patients (10.75%) were switched to surgical repair under CPB. The main causes were failure of the delivery system to pass through the VSD in 7 patients, obvious residual shunts after releasing the occluder in 5 patients, significant shedding or shifting after releasing the occluder in 4 patients, significant regurgitation in adjacent valves in 3 patients and severe intraoperative complication (bleeding) in 1 patient. Among the 154 patients who underwent transthoracic closure during the late 17 months, 6 patients (3.90%) were switched to surgical repair under cardiopulmonary bypass. The main causes were significant residual shunts after releasing the occluder in 3 patients, significant regurgitation in adjacent valves in 2 patients after releasing the occluder and failure of the delivery system to pass through the VSD in 1 patient.

Conclusions

Among all the anatomic classifications, membranous aneurysm VSD had the highest risk for switching from minimally invasive transthoracic closure to surgical repair under CPB. During the early period, the surgeons were not yet skilled with the minimally invasive transthoracic closure procedure, and the main causes of switching to surgical repair under CPB were that the delivery system could not pass through the ventricular septal defect and significant residual shunts persisted after releasing the occluder. In contrast, in the late period, the surgeons were skilled with the minimally invasive transthoracic closure procedure, and the main causes were significant residual shunts and obvious regurgitation in adjacent valves after releasing the occluder.

Rhombic-Shaped Channel Stent with Enhanced Drug Capacity and Fatigue Life

A drug-eluting stent with rhombic-shaped drug reservoirs is proposed, aimed at providing long-term drug delivery and enhanced fatigue life. Unique rhombic-shaped reservoirs or channels on the stent struts can increase the total drug capacity and improve the stress distribution for longer fatigue life, without compromising other important clinical attributes. Our rhombic-shaped channel stent increases the total drug capacity by multiple times. Its fatigue safety factor, even with the large rhombic cutouts on the stent struts, could be 50% higher than that of the conventional drug-eluting stent. A pulsed fiber-optic laser and a series of expansions and heat treatments were used to make the first prototype of our rhombic-shaped channel stent. This new concept may open up a wide variety of new treatment options and opportunities for the medical industry in the future.

Recent advances in pediatric interventional cardiology

During the last 10 years, there have been major technological achievements in pediatric interventional cardiology. In addition, there have been several advances in cardiac imaging, especially in 3-dimensional imaging of echocardiography, computed tomography, magnetic resonance imaging, and cineangiography. Therefore, more types of congenital heart diseases can be treated in the cardiac catheter laboratory today than ever before. Furthermore, lesions previously considered resistant to interventional therapies can now be managed with high success rates. The hybrid approach has enabled the overcoming of limitations inherent to percutaneous access, expanding the application of endovascular therapies as adjunct to surgical interventions to improve patient outcomes and minimize invasiveness. Percutaneous pulmonary valve implantation has become a successful alternative therapy. However, most of the current recommendations about pediatric cardiac interventions (including class I recommendations) refer to off-label use of devices, because it is difficult to study the safety and efficacy of catheterization and transcatheter therapy in pediatric cardiac patients. This difficulty arises from the challenge of identifying a control population and the relatively small number of pediatric patients with congenital heart disease. Nevertheless, the pediatric interventional cardiology community has continued to develop less invasive solutions for congenital heart defects to minimize the need for open heart surgery and optimize overall outcomes. In this review, various interventional procedures in patients with congenital heart disease are explored.

Transcatheter closure, mini-invasive closure and open-heart surgical repair for treatment of perimembranous ventricular septal defects in children: a protocol for a network meta-analysis

INTRODUCTION

Both transcatheter device closure and surgical repair are effective treatments with excellent midterm outcomes for perimembranous ventricular septal defects (pmVSDs) in children. The mini-invasive periventricular device occlusion technique has become prevalent in research and application, but evidence is limited for the assessment of transcatheter closure, mini-invasive closure and open-heart surgical repair. This study comprehensively compares the efficacy, safety and costs of transcatheter closure, mini-invasive closure and open-heart surgical repair for treatment of pmVSDs in children using Bayesian network meta-analysis.

METHODS AND ANALYSIS

A systematic search will be performed using Chinese Biomedical Literature Database, China National Knowledge Infrastructure, PubMed, EMBASE.com and the Cochrane Central Register of Controlled Trials to include random controlled trials, prospective or retrospective cohort studies comparing the efficacy, safety and costs of transcatheter closure, mini-invasive closure and open-heart surgical repair. The risk of bias for the included prospective or retrospective cohort studies will be evaluated according to the risk of bias in non-randomised studies of interventions (ROBINS-I). For random controlled trials, we will use risk of bias tool from Cochrane Handbook version 5.1.0. A Bayesian network meta-analysis will be conducted using R-3.3.2 software.

ETHICS AND DISSEMINATION

Ethical approval and patient consent are not required since this study is a network meta-analysis based on published trials. The results of this network meta-analysis will be submitted to a peer-reviewed journal for publication.

PROTOCOL REGISTRATION NUMBER

CRD42016053352.

Postprocedural Outcomes and Risk Factors for Arrhythmias Following Transcatheter Closure of Congenital Perimembranous Ventricular Septal Defect: A Single-center Retrospective Study

BACKGROUND

Currently, transcatheter closure of perimembranous ventricular septal defect (pmVSD) is a widely accepted therapeutic modality. However, arrhythmias, especially postprocedural heart blocks, are a concern and outcomes are not very clear. This study explored the outcomes and risk factors of arrhythmias associated with transcatheter device closure of pmVSD.

METHODS

A total of 395 patients diagnosed with pmVSD who successfully underwent transcatheter intervention between January 2010 and December 2015 in our center were retrospectively reviewed. Electrocardiographic data before and after the procedure were collected and analyzed. We first evaluated the potential risk factors including gender, age, weight, inlet and outlet diameters of defect, subaortic rim length, occluder size, corrected occluder size into body surface area, fluoroscopy time, presence of aneurysm, and deployment position. We compared the potential risk factors between arrhythmia and nonarrhythmia groups using univariate analysis, followed by logistic analysis for independent risk factors.

RESULTS

Various arrhythmias were detected in 95 cases (24.1%) following transcatheter closure procedure. Logistic regression analysis revealed that eccentric (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.2-7.2) and large occluders (OR 2.0, 95% CI: 1.6-2.5), as well as long fluoroscopy time (OR 1.1, 95% CI: 1.1-1.2), were correlated with postprocedural arrhythmia. During 35.5 months (range: 9-80 months) of follow-up, most of the patients (74 out of 95) reverted to normal heart rhythm.

CONCLUSIONS

The mid-term outcome of patients with arrhythmias after transcatheter closure of pmVSD was satisfactory as most of the patients recovered normal rhythm. Eccentric, large device and long fluoroscopy time increase the risk of arrhythmias after transcatheter closure of pmVSD.

Whether heart blocks post perimembranous ventricular septal defect device closure remain threatening: how could Chinese experiences impact the world?

Transcatheter closure has become one of the alternations of surgical treatment since 1988. However, cAVB occurred as a threatening incidence of 6.8% after Amplatzer VSD Occluder closure, which was quite higher than the incidence of 1% to 2% post-surgical closure, which leaded this kind of technique, was not approved by FDA. In this commentary, we reviewed the publications of cAVB following the device closure, and summarized current data of Modified Amplatzer-type Occluder during long-term follow-up, especially introduced the experiences from China, where this kind of treatment became a routine procedure for VSD children. Moreover, we carried our visualized analysis based on scientific literatures using CiteSpace to draw knowledge burst mapping, which revealed the development procedure on this interested topics, and demonstrated the role of China's works to make contributions in the field, and figured out the limitation of our researches, which supplied a basic understanding on why we could not impact the world. Finally, it concluded that transcatheter closure of pmVSD with Modified Amplatzer-type Occluder would be safe and efficient with low incidence of well controlled complications, but it failed to spread our experiences in a more scientific way. And, we hope this kind of therapy could be accepted in a wider region of the world with the increasing evidence from China.

Minimally Invasive Peratrial Device Closure of Perimembranous Ventricular Septal Defect Through a Right Infraaxillary Route: Clinical Experience and Preliminary Results

BACKGROUND

Both percutaneous and perventricular device closures of perimembranous ventricular septal defects (PmVSD) present certain drawbacks. We report our experiences with a new, minimally invasive surgery using a peratrial device closure of PmVSD through a right infraaxillary route.

METHODS

Between January 2014 and October 2015, 145 patients (71 male, 74 female) with PmVSD, aged 0.5 to 9.7 years (mean 2.8 ± 2.2) and weighing between 6.1 kg and 43 kg (mean 14.0 ± 6.6 kg) were included in this study. In patients with left lateral position, a 2- to 3-cm incision was made along the right midaxillary line. The thoracic cavity was entered through the fourth intercostal space. With the help of transesophageal echocardiography guidance, a specially designed hollow probe was inserted into the right atrium. The probe was passed through the tricuspid valve into the right ventricle. The tip of the probe was adjusted to point to or cross the defect. A flexible guidewire was inserted into the left ventricle through the channel of the probe to establish a delivery pathway. Then, the device was deployed to close the defect.

RESULTS

A total of 142 cases (97.9%) were successfully occluded, whereas 3 cases failed and were converted to cardiopulmonary bypass operation through the original incision. The device size ranged from 4.0 to 10.0 mm (mean 5.1 ± 1.4 mm), and all devices were concentric. Follow-up in all patients ranged from 1.0 to 22.8 months (mean 9.9 ± 5.6) and revealed no evident valve regurgitation, no complete atrioventricular block, and no device dislocation.

CONCLUSIONS

This new minimally invasive technique of peratrial device closure through a right infraaxillary route under transesophageal echocardiography guidance was shown to be a safe, effective, feasible, and cosmetically superior treatment for PmVSD.

Surgical strategies and novel alternatives for the closure of ventricular septal defects

A variety of therapies are available to close ventricular septal defects (VSDs). These include surgical closure on bypass, percutaneous device closure, as well as perventricular hybrid closure. Due to the incidence of heart block (1-5%) associated with percutaneous device closure of perimembranous VSDs, surgical closure presently remains the gold standard and preferred therapy for these defects. Therapeutic options are more varied for muscular VSDs. Beyond infancy, transcatheter closure offers excellent results with low morbidity and mortality, without the need for cardiopulmonary bypass. Infants however have a higher incidence of adverse events using a percutaneous approach. Large mid-muscular VSDs in infants can be treated successfully using a hybrid approach, surgical closure on bypass or a percutaneous approach. However, VSDs located apically or anteriorly are difficult to identify surgically and for these infants, perventricular hybrid closure should be considered as the preferred therapeutic modality. However, some VSD's also can be closed percutaneously.

Effectiveness and Safety of Transcatheter Closure of Perimembranous Ventricular Septal Defects in Adults

This study was designed to determine the long-term safety and efficacy of using modified double-disk occluders for perimembranous ventricular septal defect (pmVSD) closure in adults. From January 2004 to December 2014, 337 adults with pmVSDs were treated through transcatheter intervention using 2 types of double-disk occluders; 302 patients received a symmetrical concentric pmVSD occluder, and 35 patients received an asymmetrical concentric pmVSD occluder. All patients were followed up through electrocardiography and transthoracic echocardiography until June 2015. The success rate was 100% for both procedures. During the median 71-month follow-up period, no cases of infective endocarditis, cerebrovascular accidents, heart failure, or death occurred. Two major adverse events (0.6%) were recorded: complete atrioventricular block requiring surgical treatment in one patient and severe tricuspid valvular regurgitation requiring surgical repair in another patient. Cardiac conduction block was the most common minor adverse event. The mean left ventricular (LV) end-diastolic volume decreased from 96.6 ± 23.2 ml before intervention to 86.0 ± 22.0 ml (p <0.05) at the 6-month follow-up visit. Previously enlarged LV chambers decreased to normal sizes during the follow-up period. In conclusion, transcatheter closure of pmVSDs using modified double-disk occluders was both safe and effective and yielded excellent long-term results in adults. The potential benefits of this intervention included remodeling of the heart, a reduced incidence of infective endocarditis and prevention of LV volume overload.

Percutaneous Closure of Perimembranous Ventricular Septal Defects Using the Second-Generation Amplatzer Vascular Occluders

Earlier attempts at percutaneous closure of perimembranous ventricular septal defects (Pm VSDs) were abandoned because of incidence of heart block likely as a result of device rigidity and/or oversizing. This is retrospective review and data reporting of patients who underwent percutaneous closure using the softer second-generation Amplatzer vascular occluders; namely the Amplatzer vascular plug, second generation, (AVP II) and the Amplatzer duct occluder, second generation (ADO II) in our institution. A total of 20 patients were identified; AVP II was used in 9 patients and ADO II in 11 patients. Median weight was 13.45 kg (range 6.5 to 76); age 28.5 months (range 11 to 352). After procedure, 4 were noted to have aortic insufficiency; trivial in 3 and mild in 1 (unrelated to the device). Mild tricuspid regurgitation possibly device or procedure related was seen in 4. Residual flow through the device was common after procedure and disappeared in all but 3, graded as trivial in 1, small in 2. Average follow-up period was 7.54 months ± 7.5 (1 day to 25 months). There was no incidence of heart block, bacterial endocarditis, hemolysis, device embolization, or fracture. The aortic insufficiency resolved in 1 patient and was estimated to be trivial in the remaining 3 patients. In conclusion, percutaneous closure of Pm VSDs using the softer new generation devices as the AVP II and the ADO II is feasible and safe. Longer follow-up and larger series are needed.

Transfemoral Device Occlusion and Minimally Invasive Surgical Repair for Doubly Committed Subarterial Ventricular Septal Defects

Transfemoral device occlusion and minimally invasive surgical repair are performed for doubly committed subarterial ventricular septal defect (dcVSD) to reduce the invasiveness of the conventional surgical repair through a median sternotomy. However, few studies have compared them in terms of effectiveness and cost. Inpatients with isolated dcVSD who had undergone transfemoral device occlusion or minimally invasive surgical repair from January 2011 to June 2014 were reviewed for a comparative investigation between the two procedures. Procedure success was achieved in 36 transfemoral (75 %) and in 36 surgical (100 %) procedures (p = 0.001). Transfemoral patients were older, with a VSD size similar to that of surgical patients (14.5 ± 11.7 vs 4.4 ± 2.9 years, p < 0.001; 4.5 ± 1.5 vs 4.4 ± 1.3 mm, p = 0.577, respectively). No significant difference was observed in complication rates between the two treatment groups (p = 1). No large residual shunt was observed. Small residual shunt was noted in two transfemoral patients and four surgical patients (p = 0.674). All these small residual shunts closed spontaneously during follow-up. The surgical repair costs 26 % less than the device occlusion (Yuan 22063.2 ± 343.9 vs Yuan 29970.1 ± 1335.2, p < 0.001), where most of the cost was attributed to the occluder in the amount of Yuan 19,500. Compared with device occlusion, minimally invasive surgical repair can provide superior efficacy and comparable complication rates. In addition, it is 26 % cheaper than device occlusion. In low-income countries where healthcare resources are limited, medical resources must be judiciously allocated to the treatment that allows for effective treatment of the largest number of patients.

Comparison of percutaneous device closure versus surgical closure of peri-membranous ventricular septal defects: A systematic review and meta-analysis

BACKGROUND

While percutaneous device closure (PDC) is a first-line therapy for isolated muscular ventricular septal defects (mVSD), surgery is still the preferred approach for peri-membranous ventricular septal defects (pmVSD).

OBJECTIVE

We sought to compare the outcomes of percutaneous versus open surgical closure of pmVSDs.

METHODS

PubMed, Cochrane Library, and Web of Science databases were searched through October 15, 2014 for English language studies comparing outcomes of PDC with surgical closure of pmVSDs. Study quality, publication bias, and heterogeneity were assessed. A meta-analysis of selected studies was performed using a random effects model. Comparison was done for early (<1 month) safety and efficacy outcomes.

RESULTS

Seven studies with a total of 3,134 patients (PDC = 1,312, surgery = 1,822) were identified. Patients in the PDC group were older than those treated surgically (mean age 12.2 vs. 5.5 years, respectively). In six out of seven studies, the mean VSD size was found to be comparable between the treatment arms (PDC 4.9 mm vs. surgery 6.0 mm). Males represented 52% of patients in either group. Follow-up ranged from 5 to 42 months. No significant differences were observed between PDC vs. surgery in terms of procedural success rate [relative risk (RR): 1.00, confidence interval (CI): 0.99-1.00; P = 0.67]. Combined safety end points for major complications (early death/reoperation/permanent pacemaker) were similar in both groups (RR: 0.55, CI: 0.23-1.35; P = 0.19) as were as other outcomes like post-procedure significant residual shunt (RR: 0.69, CI: 0.29-1.68; P = 0.41), significant valvular (aortic/tricuspid) regurgitation (RR: 0.70, CI: 0.26-1.86; P = 0.47), and advanced heart block (RR: 0.99, CI: 0.46-2.14; P = 0.98). The need for blood transfusion (RR: 0.02, CI: 0.00-0.05; P < 0.001) and duration of hospital stay [standard mean difference (SMD) -2.17 days, CI: -3.12 to -1.23; P < 0.001] were significantly reduced in the PDC group.

CONCLUSION

Percutaneous closure of pmVSD when performed in a selected subgroup of patients is associated with similar procedural success rate without increased risk of significant valvular regurgitation or heart block when compared with surgical closure.

Follow-up of patients with interventional closure of ventricular septal defects with Amplatzer Duct Occluder II

Nonsurgical closure of congenital ventricular septal defects (VSD) has become increasingly acceptable with the availability of different occlusion systems. Transcatheter device treatment is used for perimembranous and muscular defects. Atrio-ventricular block remains the most troublesome complication of device closure. The aim of this study was to describe our experience with closure of VSD using the Amplatzer Duct Occluder II (ADO II) as an "off-label" approach in children and adults. Between 2004 and 2012 transcatheter closure of 31 VSD (20 perimembranous, 10 muscular VSD and 1 ruptured sinus valsalva) with ADO II was undertaken in patients between 3 months and 55 years of age and with a body weight ranging from 4 to 105 kg in our institution. In 29 of 31 procedures, the defect was successfully closed (93.5%) without any significant complications. No increase of aortic or tricuspid valve regurgitation was found in any after procedure. Small residual shunts were observed immediately after the device implantation, but disappeared during a median follow-up period of 38 months (0.4-63) in 27 of 31 patients. There was no incidence of AV block or other conductance abnormalities during implantation or follow-up. The ADO II device is safe and effective for transcatheter VSD closure, but this is still an "off-label" use. After long-term follow-up in a large number of patients this device may be approved for VSD closure in the future.

Comparison of effectiveness and cost between perventricular device occlusion and minimally invasive surgical repair for perimembranous ventricular septal defect

Perventricular device occlusion and minimally invasive surgical repair for perimembranous ventricular septal defect (pmVSD) are two typical methods to reduce the invasiveness of the conventional operation through median sternotomy. However, few comparative studies have been made between them in terms of effectiveness and cost. A review was made of the inpatients with isolated pmVSD, who had undergone perventricular device occlusion or minimally invasive surgical repair from June 2011 and January 2013 for a comparative investigation between the two procedures. The two treatment groups had similar baseline characteristics. Procedural success was achieved in 163 (94.8%) of the perventricular and 137 (98.6%) of the surgical (P = 0.136). Major complications occurred in 2 (1.2%) of the perventricular and 4 (2.9 %) of the surgical (P = 0.497), and minor complications, in 57 (33%) of the percutaneous and 49 (35.2%) of the surgical (P = 0.696). In cost, the surgical repair was 30.5% cheaper than the device occlusion (Yuan 20139 ± 3760 vs. 28970 ± 3343, P < 0.001), where most of the cost was attributed to the occluder in the amount of Yuan 19,500. Compared with perventricular device closure, minimally invasive surgical repair can provide comparable efficacy and complication rates, without the potential for developing atrioventricular block at long-term follow-up. In addition, it is 30.5% cheaper than hybrid procedure. In the low-income countries where health-care resources are limited the medical resources must be judiciously allocated to the treatment that allows for effective treatment of the largest number of patients.

An Unusual Complication of the Ventricular Septal Defect Closure by Device: Late Right Aortic Cusp Perforation

Aortic regurgitation (AR) is a rare complication of transcatheter closure of perimembranous ventricular septal defects (pmVSD). It results from iatrogenic pinching of the aortic valve by the VSD occluder or perforation by the catheter. It is usually detected during control echocardiography (ECHO). The current study reports the first case of a late AR, which resulted from late right coronary cusp perforation by the VSD occluder. The current manuscript discusses the possible causes of late cusp erosion due to occluder, advantages of early operation in such cases, and an alternative treatment method where the occluder removal is not possible at the operation.