Transcatheter closure of perimembranous ventricular septal defects using amplatzer asymmetric ventricular septal defect occluder: preliminary experience with 18-month follow up

Comparison of the clinical effect between the lower sternal incision and the left parasternal fourth intercostal incision in the transthoracic closure of ventricular septal defect

Background

To analyze the clinical effect of two different ways of minimally invasive transthoracic closure in children with ventricular septal defect (VSD).

Methods

From January 2015 to July 2019, 294 children with VSD were enrolled in the Fujian Medical University Union Hospital. Patients were divided into two groups – those who underwent VSD closure through the left sternal fourth intercostal incision (group A: n = 95) and the lower sternal incision (group B: n = 129).

Results

The operation time, bleeding volume, postoperative mechanical ventilation time, postoperative intensive care unit (ICU) monitoring time, postoperative hospitalization time and complication rate in group A were significantly lower than those in group B (P < 0.05). There was no significant difference between the two groups in the operation success rate, mechanical ventilation time and total hospitalization cost (P > 0.05).

Conclusion

The transthoracic closure of ventricular septal defect through the left sternal fourth intercostal incision is feasible, safe, cosmetic, and worth popularizing.

Transfemoral transcatheter puncture of interventricular septum in a swine model: A novel transfemoral-venous access to left ventricle with the assistance of arterio-venous circuit

OBJECTIVE

Via subclavian/jugular vein, successful puncture of interventricular septum (IVS) has been achieved transvenously. However, the approach was limited by acute entry-angle. The study was conducted to investigate a novel transcatheter puncture of IVS via femoral access and transfemoral-venous access to left ventricle (LV) through IVS.

METHODS

Via femoral artery, transcatheter puncture of mid-IVS was performed with a custom-made nickel-titanium needle and 6F-sheath in 16 healthy mini-swine. Then femoral arterio-venous circuit was established through IVS. After pre-dilation of IVS, a 20F-sheath was introduced into LV transvenously over-the-guidewire in 15 swine. Furthermore, transfemoral-venous TAVR was attempted with the approach in another swine. IVS was evaluated postoperatively and was further confirmed pathologically 2 months later.

RESULTS

All transcatheter puncture of IVS was performed successfully in LV and the mid-IVS thickness was 7.67 ± 0.98 mm. In all swine, femoral arterio-venous circuit was established via IVS, and a 20F-sheath was introduced into LV and aorta transfemoral-venously (entry-angle: 145.3 ± 12.2° in front view). After the procedure, there was one swine with moderate tricuspid-regurgitation and five swine with mild residual-shunt (2.6 ± 0.7 mm). Two months later, residual-shunt was still detected in three swine and the communication was confirmed pathologically. In other swine, no defect occurred and replacement-scar was identified along puncture-tract. In the swine underwent transfemoral-venous TAVR, prosthetic valve was deployed successfully with good function.

CONCLUSIONS

Transfemoral transcatheter puncture of IVS is feasible and safe in a swine model, and large sheath can be introduced into LV transfemoral-venously using the novel access with the aid of vessel circuit.

Percutaneous closure of perimembranous ventricular septal defect using patent ductus arteriosus occluders

OBJECTIVES

To assess the safety and efficacy of percutaneous closure of perimembranous ventricular septal defect (PmVSD) using patent ductus arteriosus (PDA) occluders.

BACKGROUND

Widespread use of conventional PmVSD closure devices has been limited by unacceptable high rate of complete heart block (CHB). The elegant design of PDA occluders is supposed to ease implantation, increase closure rate and minimize damage to adjacent structures. Thus, PDA occluders may reduce complications, especially the CHB, and offer a good alternative for PmVSD closure.

METHOD

From September 2008 to October 2015, patients who underwent attempted percutaneous VSD closure using PDA occluders were included in the study. Patient demographics, echocardiography measurements, procedure details and follow-up data until October 2017 were collected.

RESULTS

In total, 321 patients with a mean age of 15.5±12.6 years and mean a weight of 33.3±20.5 kg were included in this study. The mean defect size was 4.8±2.1 mm. Implantation was successful in 307 (95.6%) patients. The median follow-up time was 63 months (24 to 108 months). The closure rates were 89.5%, 91.5%, and 99.3% after the procedure 24 hours, 6 months and 2 years, respectively. Major complications occurred in 5 (1.7%) patients during the procedure and follow-up, including persistent CHB in 2 (0.7%) patients and device embolization in 3 (1.0%) patients. No death, disability, or other major complication was detected.

CONCLUSION

Percutaneous closure of PmVSD using PDA occluders is feasible, safe and efficacious in selected patients.

Nit-Occlud Lê VSD coil versus Duct Occluders for percutaneous perimembranous ventricular septal defect closure

OBJECTIVE

To evaluate the efficacy and safety of Nit-Occlud Lê VSD Coil versus Duct Occluders for percutaneous closure of perimembranous ventricular septal defect (pmVSD).

INTRODUCTION

VSD closure using conventional pmVSD occluders has been largely abandoned because of an unacceptable high rate of complete heart block (CHB). The advantages of Duct Occluders and VSD Coil are supposed to reduce the drawbacks of previous devices, especially CHB complications.

METHOD

Patients underwent percutaneous pmVSD closure were divided into Coil group (using VSD Coil, n = 71) and DO group (using Duct Occluders, n = 315). Patient demographics, clinical presentations, echocardiography measurements, procedure details and follow-up data were collected.

RESULT

The procedure success rate was high in both DO group (95.6%) and Coil group (97.2%, P = .53). The closure rate immediately after procedure in the DO group was higher than that in the Coil group (76.8% vs. 58.0%, P < .01). After 6 months, the closure rate was not significantly different between the 2 groups (DO group 91.3% vs. Coil group 84.1%, P = .07). The mean follow-up time was 61.4 ± 24.1 months. The major complication rate was low in both groups (DO group 1.9% vs. Coil group 1.4%, P = .78). Two patients (0.7%) in the DO group and one patient (1.4%) in the Coil group with CHB needed permanent pacemaker (P = .5). Device embolization (3 patients, 1.0%) and endocarditis (1 patient, 0.3%) occurred only in the DO group. There was no death, disability or other major complications detected in either group.

CONCLUSION

Percutaneous pmVSD closure using either Nit-Occlud Lê VSD Coil or Duct Occluders is feasible, safe and efficacious in selected patients. The main problems of Duct Occluders are unsuitable defect anatomy and device embolization while VSD Coil disadvantages are residual shunt and hemolysis.

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.

Perventricular device closure of perimembranous ventricular septal defect: effectiveness of symmetric and asymmetric occluders

Objectives

To assess safety and effectiveness of symmetric and asymmetric occluders in perventricular device closure without cardiopulmonary bypass of perimembranous ventricular septal defects (pmVSDs).

Methods

The present retrospective study enrolled 581 patients who underwent perventricular device closure of pmVSDs under transoesophageal echocardiography guidance from May 2011 to April 2016, and outpatient electrocardiography and transthoracic echocardiography assessments at 1, 3, 6 and 12 months, and yearly thereafter.

Results

The overall success rate of device implantation was 92.6% (43 surgical conversions immediately). Between patients receiving symmetric ( n  = 353) and asymmetric ( n  = 185) occluders, there were no significant differences in age, weight and defect diameter distributions; however, both before discharge and at mean 28.6 ± 21.2 (range, 1-60)-month follow-up, the symmetric group had lower rates of trivial residual shunt (5.7% vs 11.4%, P  = 0.018; and 0.8% vs 5.9%, P  = 0.001) and bundle branch block (0.8% vs 5.4%, P  = 0.002; and 0.6% vs 3.8%, P  = 0.009); and at follow-up, the asymmetric group had lower residual shunt (47.6% vs 85.0%, P  = 0.020) and similar branch block (30.0% vs 33.3%, P  = 1.000) disappearance rates. There were no severe complications, i.e. aortic regurgitation, malignant arrhythmias, haemolysis or device dislocation.

Conclusions

Perventricular device closure of pmVSDs appears safe and effective with symmetric and asymmetric occluders. However, the lower residual shunt disappearance and higher branch block incidence rates for asymmetric occluders would favour more proactive conversion to surgical repair immediately when residual shunt is present intraoperatively.

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 of perimembranous ventricular septal defects with the Amplatzer Vascular Plug-II

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of the Amplatzer Vascular Plug-II used for the closure of perimembranous ventricular septal defects.

BACKGROUND

There are no FDA-approved transcatheter devices for the closure of perimembranous ventricular septal defects. Several studies have reported on the use of various devices either off-label or under clinical trial protocols. However these reports have described significant adverse events including residual shunts, complete heart block, arrhythmia, and new valve regurgitations. Thus far, no study on the Amplatzer Vascular Plug-II has been reported.

METHODS

We conducted a 4-year retrospective chart review from August, 2010 to August, 2014, of patients with perimembranous ventricular septal defects associated with ventricular septal aneurysm who underwent transcatheter closure using the Amplatzer Vascular Plug-II.

RESULTS

A total of 16 patients underwent Amplatzer Vascular Plug-II transcatheter closure of their perimembranous ventricular septal defects. The median age was 2.56 years (range: 0.5-27.3). Their median weight was 13.0 kg (range: 6.9-71.6). The left ventricular median defect size was 9.3 mm (range: 5.9-14.4). The right ventricular median defect size was 3.6 mm (range: 2.3-5.8). All the patients underwent successful device implantation with 83% of the patients having complete echocardiographic closure at the 1-year follow-up; however, one procedure was complicated by early device embolisation. The device was successfully retrieved and replaced with a larger device. There were no device-related outflow tract obstructions, rhythm abnormalities, or haemolysis.

CONCLUSION

Application of the Amplatzer Vascular Plug-II for closure of perimembranous ventricular septal defects appears to be a safe and effective treatment option. Prospective clinical trials and longer follow-up periods are warranted.

Medium to long-term echo follow-up after ventricular septal defect device closure

OBJECTIVE

We aimed to assess the medium to long-term results of echocardiographic follow-up of perimembranous and muscular ventricular septal defect closure with various Amplatzer devices.

METHODS

We successfully closed ventricular septal defects percutaneously in 45/49 patients. There were 35 perimembranous and 10 muscular ventricular septal defects. The median age and weight was 8.50 years (range 2-36.70 years) and 24 kg (range 10-106 kg), respectively. The median size of the ventricular septal defect was 7 mm (range 3-14 mm) on transthoracic echocardiography, 6 mm (range 4-15 mm) on transesophageal echocardiography, and 6 mm (range 3-14 mm) on left ventricular angiography. The median pulmonary-to-systemic blood flow ratio was 1.40 (range 1.0-3.0).

RESULTS

In the 49 attempted cases, the procedure was successful in 45, with a success rate of 91.84%. At a mean follow-up of 54.50 months, echocardiography showed complete closure in 41 (91%) patients and 4 (9%) had a tiny (1-2 mm) residual defect. New-onset aortic regurgitation was seen in 6 (13.3%) patients at 54.50 months, but it was mild in nature. Tricuspid valve regurgitation was observed in 13 (29%) patients at 54.50 follow-up, of whom 10 (22%) had mild and 3 (7%) had moderate regurgitation.

CONCLUSION

Transcatheter closure of perimembranous and muscular ventricular septal defects is effective, however, these patients need to be followed up regularly to detect device-related problems, specifically, aortic and tricuspid valve regurgitation.

Echocardiographic Guided Closure of Perimembranous Ventricular Septal Defects

BACKGROUND

Transesophageal echocardiogram-guided minimally invasive periventricular device closure of perimembranous ventricular septal defects (pmVSDs) without cardiopulmonary bypass is a treatment option for pmVSDs. We introduce our improvements to this technique and mid-term follow-up results.

METHODS

From May 2011 to May 2014, 187 patients with pmVSDs aged 6 months to 31 years (8.2 ± 10.2 years) were enrolled in this study. The procedure was performed through a new transthoracic approach of 1 to 2 cm without sternotomy. Device selection and the operative procedure were monitored by transesophageal echocardiogram. The patients underwent follow-up examinations of echocardiography and electrocardiogram at 1 month, 3 months, 6 months, and 1 year after the operation and annually thereafter.

RESULTS

The defects were closed successfully in 179 patients (95.7%), and in 8 patients the operation was converted to conventional surgical repair. Six patients (3.4%) had an incomplete right bundle branch block. One patient experienced an intermittent complete atrioventricular block on the fourth day after the operation, and sinus rhythm was restored by corticosteroid therapy after 5 days. A trivial residual shunt was observed in 8 patients (4.5%) during the procedure. The average hospital stay was 3.1 ± 0.9 days. Follow-up in all patients ranged from 1 month to 36 months (median, 12.6 months), and aortic regurgitation, malignant arrhythmia, and device dislocation were not observed in any patients. However, 3 patients (1.7%) still had a trivial residual shunt at their last follow-up.

CONCLUSIONS

Periventricular device closure through a modified transthoracic approach without sternotomy is a potentially safe and effective treatment option for pmVSDs. Controlled studies with long-term follow-up are necessary.

Efficacy and Safety of Using Amplatzer Ductal Occluder for Transcatheter Closure of Perimembranous Ventricular Septal Defect in Pediatrics

Background:

Perimembranous Ventricular Septal Defect (PMVSD) is the most common subtype of ventricular septal defects. Transcatheter closure of PMVSD is a challenging procedure in management of moderate or large defects.

Objectives:

The purpose of this study was to show that transcatheter closure of perimembranous ventricular septal defect with Amplatzer Ductal Occluder (ADO) is an effective and safe method.

Patients and Methods:

Between April 2012 and April 2013, 28 patients underwent percutaneous closure of PMVSD using ADO. After obtaining the size of VSD from the ventriculogram a device at least 2 mm larger than the narrowest diameter of VSD at right ventricular side was chosen. The device deployed after confirmation of its good position by echocardiography and left ventriculography. Follow up evaluations were done 1 month, 6 months, 12 months and yearly after discharge with transthoracic echocardiography and 12 lead electrocardiography.

Results:

The mean age of patients at procedure was 4.7 ± 6.3 (range 2 to 14) years, mean weight 14.7 ± 10.5 (range 10 to 40) kg. The mean defect size of the right ventricular side was 4.5 ± 1.6 mm. The average device size used was 7.3 ± 3.2mm (range 4 to 12 mm). The ADOs were successfully implanted in all patients. The VSD occlusion rate was 65.7% at completion of the procedure, rising up to 79.5% at discharge and 96.4% during follow-up. Small residual shunts were seen at completion of the procedure, but they disappeared during follow-up in all but one patient. The mean follow-up period was 8.3 ± 3.6 months (range 1 to 18 months). Complete atrioventricular block (CAVB), major complication or death was not observed in our study.

Conclusions:

Transcatheter closure of PMVSD with ADO in children is a safe and effective treatment associated with excellent success and closure rates, but long-term follow-up in a large number of patients would be warranted.

Retrograde closure of perimembranous ventricular septal defect using muscular ventricular septal occluder: a single-center experience of a novel technique

We herein report the advantages of retrograde ventricular septal defect (VSD) closure using a muscular VSD device for perimembranous VSDs. Perimembranous VSDs are conventionally closed by an antegrade technique (arteriovenous looping technique) using a patent ductus arteriosus or asymmetric perimembranous VSD device. However, we used a symmetrical muscular VSD device in all cases described in this report. Use of the antegrade technique for the first few patients with VSD resulted in prolonged procedural and fluoroscopic times and frequent slippage of the device into the right ventricle. Subsequent use of the retrograde technique shortened the procedural time and allowed for easier closure of the perimembranous VSD. We performed retrograde closure of perimembranous VSDs using a symmetrical muscular VSD device in 130 patients. We obtained a high rate of successful deployment (88.5%) and a low rate of complications (6.0%). We also achieved shorter procedural and fluoroscopic times than those associated with the antegrade technique.

A case of late-onset sustained ventricular tachycardia following deployment of Amplatzer-type perimembranous VSD occluder

Transcatheter closure of ventricular septal defect (VSD) has been widely used worldwide. Despite high success rate and minimal operative mortality, arrhythmia during and post-operation has been frequently observed. However, sustained ventricular tachycardia following deployment of occluder has not been reported. In this present case, we present one rare case of late-onset sustained ventricular tachycardia, which developed 71 hr after deployment of an Amplatzer-type occluder for perimembranous VSD (PmVSD) in a 3-year and 5-month-old boy. The sustained ventricular tachycardia was successfully corrected with the administration of lidocaine, amiodarone, and dexamethasone. The reoccurrence of ventricular tachycardia was not observed in the most recent follow-up at 6 month. In summary, the current case indicated that sustained ventricular tachycardia could occur following deployment of Amplatzer-type occluder for PmVSD, which could be corrected with antiarrhythmic drugs.

A new coated nitinol occluder for transcatheter closure of ventricular septal defects in a canine model

Aims. This study evaluated feasibility and safety of implanting the polyester-coated nitinol ventricular septal defect occluder (pcVSDO) in the canine model. Methods and Results. VSD models were successfully established by transseptal ventricular septal puncture via the right jugular vein in 15 out of 18 canines. Two types of VSDOs were implanted, either with pcVSDOs (n = 8) as the new type occluder group or with the commercial ventricular septal defect occluders (VSDOs, n = 7, Shanghai Sharp Memory Alloy Co. Ltd.) as the control group. Sheath size was 10 French (10 Fr) in two groups. Then the general state of the canines was observed after implantation. ECG and TTE were performed, respectively, at 7, 30, 90 days of follow-up. The canines were sacrificed at these time points for pathological and scanning electron microscopy examination. The devices were successfully implanted in all 15 canines and were retrievable and repositionable. There was no thrombus formation on the device or occurrence of complete heart block. The pcVSDO surface implanted at day 7 was already covered with neotissue by gross examination, and it completed endothelialization at day 30, while the commercial VSDO was covered with the neotissue in 30th day and the complete endothelialization in 90th day. Conclusion. The study shows that pcVSDO is feasible and safe to close canine VSD model and has good biocompatibility and shorter time of endothelialization.

Transcatheter closure of perimembranous ventricular septal defect using Amplatzer ductal occluder

OBJECTIVE

To show that transcatheter closure of perimembranous ventricular septal defect (PMVSD) with the Amplatzer ductal occluder (ADO, AGA Medical Corp, Plymouth, Minnesota) is a safe and effective treatment option.

BACKGROUND

Transcatheter closure of PMVSD is a challenging procedure. Recently, the Amplatzer PMVSD occluder (APMVSDO, AGA Medical Corp, Plymouth, Minnesota) has been shown to be effective in closing hemodynamically significant PMVSDs. However, the high incidence of complete atrioventricular block (CAVB) after device occlusion of a PMVSD has been a hot issue as well.

METHODS

Among several devices used in closing PMVSD percutaneously, we prefer the ADO because of the anatomic resemblance between PMVSD with aneurysm and patent ductus arteriosus, and it has no right ventricular disc which may contribute to the occurrence of CAVB.

RESULTS

Between August 2009 and May 2012, 21 patients (5 males and 16 females) underwent percutaneous PMVSD closure using ADO. The patients' ages ranged from 3 to 42 years (median: 7 years), and their weights ranged from 18 kg to 60 kg (median: 27 kg). All patients showed echocardiographic signs of left ventricular volume overload and trivial to small mitral regurgitation (Qp/Qs = 1.7 ± 0.4). The mean defect size of the right ventricular side was 4.3 ± 1.0 mm. Devices 2 mm larger than the measured narrowest VSD diameter were selected in most patients. The ADOs were successfully implanted in all patients without any significant complications except one transient CAVB, one case of delivery wire fracture, and one case of surgery due to significant residual leak. Small residual shunts were observed immediately after the device implantation, but they disappeared during follow-up for 18 of 20 patients. The mean follow-up period was 20 ± 9 months, and CAVB or aortic regurgitation was not observed in all patients.

CONCLUSION

Transcatheter closure of PMVSD with the ADO is a safe and promising treatment option, but long-term follow-up in a large number of patients would be warranted.

Investigation of membranous ventricular septal defect complicated with tricuspid regurgitation in ventricular septal defect occlusion

This study aimed to explore the mechanism of membranous ventricular septal defect complicated with tricuspid regurgitation and the significance of ventricular septal defect occlusion by echocardiography. A total of 43 patients with membranous ventricular septal defect complicated with tricuspid regurgitation were observed by echocardiography and the changes in length, area and volume of tricuspid regurgitation prior to and following ventricular septal defect occlusion were measured. There were four different mechanisms of membranous ventricular septal defect complicated with tricuspid regurgitation. The various indices of tricuspid regurgitation volume were significantly reduced following occlusion. Ventricular septal defect occlusion significantly reduces tricuspid regurgitation volume complicated with membranous ventricular septal defect and echocardiography is an ideal method to detect these changes.

Closure of perimembranous ventricular septal defects with aneurysmal tissue using the Amplazter Duct Occluder I: lessons learned and medium term follow up

OBJECTIVES

The aim of this report is to describe our experience with closure of perimembranous ventricular septal defects (PMVSD) with aneurysm using the Amplatzer Duct Occluder I (ADO I).

BACKGROUND

Atrio-ventricular block (AVB) remains the most troublesome complication of device closure of PMVSDs. Many PMVSDs are associated with an aneurysm that protrudes into the right ventricle. We believe that devices implanted entirely within the VSD aneurysm avoid the risk of AVB.

METHODS

A retrospective analysis of patients with PMVSD and aneurysm who underwent attempted ADO I device closure between 3/2004 and 8/2010 [Rady Children's Hospital-San Diego (n = 16), Mattel Children's Hospital at UCLA (n = 4), and Straub Hospital in Honolulu (n = 1)].

RESULTS

Twenty-one patients (16 male) with PMVSD and aneurysm underwent cardiac catheterization for the purpose of VSD closure using an ADO I. Nineteen patients had successful ADO I implantation with the following devices: 10/8 (n = 8), 8/6 (n = 7), 6/4 (n = 3) and 12/10 (n = 2). The procedure was aborted in 2 cases due to temporary AVB and ventricular ectopy during catheterization. One patient developed hemolysis due device malposition and had surgical device retrieval and VSD closure. One patient had new trivial tricuspid regurgitation and in 5/19 the tricuspid regurgitation improved post device closure. Transient accelerated junctional rhythm occurred within 24 hr in 4 patients and nonsustained slow ventricular tachycardia occurred in one patient. At latest follow-up (up to 6 years, median 1.9 years) 11/18 had no residual shunt, 4/18 had trivial and 3/18 small residual shunt. No AVB has been observed.

CONCLUSIONS

Percutaneous closure of PMVSD with aneurysm using the ADO I appears to have acceptable efficacy and risk. Atrio-ventricular block in up to mid-term follow up was not encountered.

Changes in serum natriuretic peptide levels after percutaneous closure of small to moderate ventricular septal defects

Background. B-type natriuretic peptide has been shown to be a very sensitive and specific marker of heart failure. In this study, we aimed to investigate the effect of percutaneous closure of ventricular septal defects with Amplatzer septal occluders on brain natriuretic peptide levels. Methods. Between 2008 and 2011, 23 patients underwent successfully percutaneous ventricular septal defect closure in 4 cardiology centers. Brain natriuretic peptide levels were measured in nine patients (4 male, mean ages were 25.3 ± 14.3) who underwent percutaneous closure with Amplatzer occluders for membranous or muscular ventricular septal defects were enrolled in the study. Brain natriuretic peptide levels were measured one day before and one month after the closure. Patients were evaluated clinically and by echocardiography one month after the procedure. Results. Percutaneous closures of ventricular septal defects were successfully performed in all patients. There was not any significant adverse event in patients group during followup. Decrease in brain natriuretic peptide levels after closure were statistically significant (97.3 ± 78.6 versus 26.8 ± 15.6, P = 0.013). Conclusion. Brain Natriuretic Peptide levels are elevated in patients with ventricular septal defects as compared to controls. Percutaneous closure of Ventricular Septal Defect with Amplatzer occluders decreases the BNP levels.

Arrhythmias after transcatheter closure of perimembranous ventricular septal defects with a modified double-disk occluder: early and long-term results

With the development of interventional techniques and devices, transcatheter closure of perimembranous ventricular septal defect has been widely performed. However, there has been a lack of long-term follow-up results about postoperative ECG changes of PmVSD patients. We report our experience of early and late arrhythmias after transcatheter closure of PmVSD with a modified double-disk occluder (MDVO). We performed a retrospective review of 79 patients (47 males, 32 females) between September 2002 and May 2007 who underwent transcatheter closure of perimembranous ventricular septal defect. Symmetric and asymmetric PmVSD occluders were used. The diameter of the evaluated defects ranged from 3 to 12 mm, as measured by TTE and 3 to 15 mm by left ventriculography. Most cases of PmVSD were treated successfully with a single procedure, resulting in a successful closure rate of 97% (77/79 patients). There was no death in any of the patients. After the operation, 79 patients were followed-up for a range of 10-76 months (35.3 ± 17.4 months). In this series, 11 cases of incomplete right bundle branch block and five cases of complete right bundle branch block occurred during the early period after operation. During long-term follow-up, these issues declined in prevalence to five and four cases, respectively. Moreover, reversible third-degree AVB occurred during closure or after the procedure, and two of the three patients with reversible AVB received a temporary heart pacemaker implantation. These patients recovered 1 h, 6 days, and 9 days later, respectively. During 10-76 months of follow-up, no complications occurred in any of the patients, including residual shunt, severe aortic valve, or tricuspid valve regurgitation. Device closure of perimembranous ventricular septal defects with a modified double-disk occluder (MDVO) resulted in excellent closure rates and acceptably low arrhythmia rates.

Does the technique of interventional closure of perimembranous ventricular septal defect reduce the incidence of heart block?

OBJECTIVE

To describe the difficulties and differing techniques in the transcatheter placement of amplatz ventricular septal defect devices to close perimembranous ventricular septal defects and place these in the context of the expanding literature on ventricular septal defect catheter closure.

BACKGROUND

Surgery remains the established first-line therapy for closure of haemodynamically significant perimembranous ventricular septal defects. Transcatheter techniques appeared to promise a possible alternative, obviating the need for cardiac surgery. However, significant technical and anatomical constraints coupled with ongoing reports of a high incidence of heart block have prevented these hopes from being realised to any significant extent. It is likely that there are important methodological reasons for the high complication rates observed. The potential advantages of transcatheter perimembranous ventricular septal defect closure over surgery warrant further exploration of differing transcatheter techniques.

METHODS

Between August, 2004 and November, 2009, 21 patients had a perimembranous ventricular septal defect closed with transcatheter techniques. Of these, 14 were closed with a muscular amplatz ventricular septal defect device. The median age and weight at device placement were 8 years, ranging from 2 to 19 years, and 18.6 kilograms, ranging from 10 to 21 kilograms, respectively.

RESULTS

There were 25 procedures performed on 23 patients using 21 amplatz ventricular septal defect devices. Median defect size on angiography was 7.8 millimetres, ranging from 4 to 14.3 millimetres, with a median device size of 8 millimetres, ranging from 4 to 18 millimetres, and a defect/device ratio of 1.1, with a range from 0.85 to 1.33. Median procedure time was 100 minutes, with a range from 38 to 235 minutes. Adverse events included device embolisation following haemolysis in one, and new aortic incompetence in another, but there were no cases of heart block. Median follow-up was 41.7 months, with a range from 2 to 71 months.

CONCLUSIONS

Evaluating transcatheter closure of perimembranous ventricular septal defect using amplatz ventricular septal defect devices remains important, if a technically feasible method with low and acceptable complication rates is to be identified. Incidence of heart block may be minimised by avoiding oversized devices, using muscular devices, and accepting defeat if an appropriately selected device pulls through. Given the current transcatheter technologies, the closure of perimembranous ventricular septal defects should generally be performed in children when they weigh at least 10 kilograms.

Transcatheter closure of perimembranous ventricular septal defects (VSD) with VSD occluder: early and mid-term results

Results of perimembranous ventricular septal defects (pmVSD) transcatheter closure have been reported in the literature, mostly with the Amplatzer VSD device (muscular or eccentric) (AGA Medical Corp., Golden Valley, MN, USA). However, the data of percutaneous closure of pmVSD with VSD occluder (VSD-O) made in China are still limited. We sought to analyze the safety, efficacy, and follow-up results of percutaneous closure of pmVSD with VSD-O made in China. Seventy-eight patients underwent percutaneous closure of pmVSD at our institution between February 2005 and June 2007. A VSD device made in china (Huayishengjie Medical Corp., Beijing, China) was used in all subjects. The mean age at closure was 11 years (range 2.5-44 years). The attempt to place the device was successful in 74 patients (94.9%). The median device size used was 8 mm (range 5-16 mm). No deaths occurred. Total occlusion rate was 62.8% at completion of the procedure, rising to 87.2% at discharge and 99% during the follow-up. A total of eight early complications occurred (10.3%), but in all subjects these were transient. The median follow-up was 32 months. The most significant complication was complete atrioventricular block (cAVB) in the early phase (five subjects, 6.4%) and during the follow-up (one subject, 1.3%), and there was no need for pacemaker implantation in six subjects. Logistic regression analysis showed that the only variable significantly associated with the occurrence of this complication was age at the time of the procedure (p = 0.025; OR 0.22). All subjects experiencing this problem were <5 years old. Percutaneous pmVSD closure used VSD-O made in China is associated with excellent success and closure rates, no mortality, and low morbidity. Nowadays, pmVSD percutaneous closure is a valuable alternative to surgery. Longer follow-up data and improvements in device characteristics are needed to reduce the risk of cAVB.

Transcatheter closure of perimembranous ventricular septal defect in children: safety and efficiency with symmetric and asymmetric occluders

OBJECTIVES

This study was designed to determine the safety and efficiency of asymmetric and symmetric ventricular septal occluders (AVSDOs and SVSDOs, respectively) for closure perimembranous ventricular septal defect (PMVSD) in children.

METHODS

Between January 2003 and December 2007, 142 children with PMVSD were treated with occluders (64 with AVSDOs and 78 with SVSDOs).

RESULTS

The defect diameter was 5.3 ± 1.1 mm in the AVSDO group and 5.4 ± 1.3 mm in the SVSDO group (P > 0.05). The success rates were similar between two groups [93.8% (AVSDO) vs. 94.9% (SVSDO), P > 0.05]. Two patients in the AVSDO group were switched to the SVSDO group due to residual shunts, and one patient in the SVSDO group was switched due to aortic regurgitation after deployment of the occluder. After procedure, 17 patients [seven with AVSDOs and nine with SVSDOs (P > 0.05)] developed various types of heart block (HB). Among them, 13 patients converted to the normal sinus rhythm. The remaining four cases had not recovered at the end of the study.

CONCLUSIONS

Transcatheter closure of PMVSD using both AVSDO and SVSDO was safe and effective. Development of HB was the main complication for both devices.

Percutaneous closure of ventricular septal defect associated with tunnel-shaped aneurysm using the Amplatzer duct occluder

Different devices have been used for percutaneous closure of ventricular septal defects (VSDs). Over the past 6 months, we have used the Amplatzer duct occluder for VSDs associated with tunnel-shaped aneurysm in three patients here at our institution. Due to the anatomic resemblance between such VSDs and the duct occluder, we selected this device for percutaneous closure. There was trivial residual shunt in one patient. All three patients tolerated the procedure well and there were no untoward complications.

Transcatheter closure of perimembranous ventricular septal defects: early and long-term results

OBJECTIVES

We sought to analyze safety, efficacy, and follow-up results of percutaneous closure of perimembranous ventricular septal defects (pmVSD).

BACKGROUND

Results of pmVSD transcatheter closure have been reported in the literature; however, follow-up data are still limited.

METHODS

Between January 1999 and June 2006, 104 patients underwent percutaneous closure of a pmVSD at our institution. An Amplatzer VSD device (muscular or eccentric) (AGA Medical Corp., Golden Valley, Minnesota) was used in all subjects.

RESULTS

The mean age at closure was 14 years (range 0.6 to 63 years). The attempt to place a device was successful in 100 patients (96.2%). The median device size used was 8 mm (range 4 to 16 mm). No deaths occurred. Total occlusion rate was 47% at completion of the procedure, rising to 84% at discharge and 99% during the follow-up. A total of 13 early complications occurred (11.5%), but in all but 2 subjects (1.9%) these were transient. The median follow-up was 38.5 months. The most significant complication was complete atrioventricular block (cAVB), which required pacemaker implantation in 6 subjects (5.7%; 2 in the early phase and 4 during the follow-up). Cox proportional hazards regression analysis showed that the only variable significantly associated with the occurrence of this complication was age at the time of the procedure (p = 0.028; relative risk 0.25). All subjects experiencing this problem were <6 years old.

CONCLUSIONS

In the current era and in experienced hands, pmVSD closure can be performed safely and successfully. The major concern is the occurrence of cAVB; therefore, very careful monitoring of rhythm is mandatory during follow-up.

Significant aortic regurgitation associated with transcatheter closure of perimembranous ventricular septal defects with a deficient aortic rim

We report on two patients who developed significant aortic regurgitation during transcatheter closure of a perimembranous ventricular septal defect, both requiring further surgical intervention. Both patients were noted prior to the procedure to have limited subaortic margins to the defect. The potential mechanisms for development of aortic regurgitation in this setting are discussed.

Transcatheter closure of perimembranous ventricular septal defect: is the risk of heart block too high a price?

The late development of heart block in paediatric patients following device closure of a perimembranous ventricular septal defect may be a cause for concern.