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

Hybrid Interventions in Congenital Heart Disease

Hybrid interventions in congenital heart disease (CHD) embody the inherent collaboration between congenital interventional cardiology and cardiothoracic surgery. Hybrid approaches to complex and common lesions provide the opportunity to circumvent the limitations of patient size, vascular access, severity of illness, and anatomy that would otherwise be prohibitive to surgical and percutaneous techniques alone. This review describes several important hybrid approaches to interventions in CHD.

Transcatheter Ventricular Septal Defect Closure with Lifetech™ Konar-MF Occluder in Infants Under 10 kg with Only Using Venous Access

Transcatheter closure of VSD remains a complex procedure in infants with technical challenges and carries the risk of significant complications, due to its complex anatomical morphology and closed proximity to the atrioventricular valves and the conduction system. In this article, we presented transcatheter VSD closure in infants under 10 kg using the Lifetech Konar-MF device via only venous route without TEE guidance and arterial access. Between January 2021 and May 2023, a total of 34 patients weighing less than 10 kg who underwent transcatheter VSD closure antegradely with Lifetech™ Konar-Multifunctional (MF) occluder were included in the study. The mean age of the patients was 8.1 (3.5-35) months. Average weight was 6.5 kg (range 4.5-10 kg). VSD was perimembranous in 27 patients (79.4%). Successful device placement was achieved in all 34 patients. However, device embolization occurred in three patients. One of the patients was successfully implanted with a one size larger device, the surgical closure was performed other two cases. TR occurred in seven patients (20.6%) after releasing devices. None of the patients developed complete heart block. Right bundle branch block developed in two patients. Residual shunt was observed in 9 patients (six small, two moderate, and one large). During follow-up, residual shunt disappeared in six of these patients and only mild residual shunt remained in the other four patients which have not required any further intervention. Transcatheter closure of VSD with Lifetech Konar-MF device is safe and effective in infants less than 10 kg via only venous access with a high success rate and low complication rate. In these patients, transcatheter VSD closure can be performed by excluding the risk of complications that may occur due to AV loop formation, arterial intervention, endotracheal intubation and TEE use.

Experience of Percutaneous Closure of Ventricular Septal Defects in 140 Patients With Different Duct Occluders in a Tertiary Care Rural Hospital in Central India

Background Ventricular septal defects (VSDs) are the most common type of septal defects in early infants and are very complicated. This has paved the way for the development of new minimally invasive procedures for interventional cardiologists. This study presents our experience using duct occluders instead of conventional ventricular septal devices in the Department of Cardiology at Acharya Vinoba Bhave Rural Hospital (AVBRH) in central rural India. This study aimed to review success and complications and assess safety and its relation to age, sex, size of the VSDs, type of VSD, and types of devices used after transcatheter closure of perimembranous and muscular VSDs using various types of duct occluders. Methodology This retrospective study included patients who underwent percutaneous VSD device closure at the AVBRH between July 2017 and December 2020. We reviewed the patients' medical records to recognize imaging, clinical, and interventional data pre- and post-procedure and at the last follow-up. Results The success rate of VSD closure was 98.6%, one (0.7%) out of 81 females developed a complication due to device dislodgement, and one male aged six years (0.7%) out of 59 developed a post-procedural complication; hence, the total failure rate was 1.4%. The perimembranous type had no complication, and the muscular type had two (14.3%) unsuccessful procedures. Conclusion This study has concluded an impressive percentage of VSD closure, showing no mortality and low morbidity, using a percutaneous approach with different duct occluders. As the type of device used is not correlated with device failure and failure rate, duct occluders will be financially helpful in the closure of VSD in indicated patients.

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.

A review of the therapeutic management of multiple ventricular septal defects

BACKGROUND AND AIM

We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes, including reinterventions, for each subset.

METHODS

We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, associated anomalies, and the effect of severe pulmonary hypertension.

RESULTS

Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between 0% and 14.2%, with morbidity estimated between 6% and 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with the need for reoperation being over four times higher. Perventricular hybrid approaches are useful for the closure of high anterior or apical defects. Overall, the results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical subsets.

CONCLUSIONS

We have addressed the approaches, and the results, of therapeutic treatment in terms of coexisting discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.

Transcatheter closure of ventricular septal defects in children less than 10 kg: experience from a tertiary care referral hospital in Eastern India

OBJECTIVE

To assess the feasibility of percutaneous transcatheter device closure of ventricular septal defects in children weighing less than 10 kg.

BACKGROUND

Although percutaneous transcatheter device closure of ventricular septal defect is a well-established method of treatment in older children and adolescents, there is limited data on device closure in small children weighing less than 10 kg. We present our institutional experience of transcatheter VSD closure in children weighing less than 10 kg.

METHOD

Medical records were reviewed for 16 children, who were selected for device closure of ventricular septal defects based on the inclusion criteria.

RESULTS

Out of 65 patients with a diagnosis of ventricular septal defect, 16 children less than 10 kg were attempted for percutaneous device closure. In 13 patients, the device was successfully released, and 3 patients needed surgical closure of the defect. Mean age and weight of the patients were 17.3 ± 12.7 months and 6.8 ± 3.2 kg, respectively. Mean defect size was 6 mm (range 3-10). There was no incidence of device embolisation or heart block or death. Five patients had residual left-to-right shunt immediately after the device release, which got closed by the first month's follow-up. We had one accidental perforation of right ventricular free wall at the time of crossing of the defect, which was successfully repaired surgically.

CONCLUSION

Percutaneous device closure of ventricular septal defect in small children with weight below 10 kg is feasible with good short-term outcome. Careful patient selection is essential for procedural success and to avoid complications.

Perimembranous ventricular septal defect closure via ultra-minimal trans intercostal incision in children

AIMS

This study aimed to investigate the safety, feasibility and, availability of perimembranous ventricular septal defect (PmVSD) closure via a left parasternal ultra-minimal trans intercostal incision in children.

METHODS AND RESULTS

From January 2015 to January 2019, 131 children with restrictive PmVSDs were enrolled in this study and successfully done in 126 patients (96.18%). PmVSDs were occluded via an ultra-minimal trans intercostal incision (≤1 cm), and the entire occlusive process was guided and monitored by TEE. A pericardium hanging technique was employed without sternal incision. PmVSDs were closed through a short delivery sheath assembled using a concentric occluder device. All patients were followed up for a period ranging from18 months to 24 months. Thirteen patients with PmVSD had aneurysm of membranous septum (AMS). Multistream (≥2) PmVSDs with AMS were found in 11 cases. After the operation, mild residual shunt beside the amplatzer occluder in one patient was found and had self-healing result during the 5-month follow-up period. Five patients transferred to ventricular septal defect repair operation under direct visualization with a cardiopulmonary bypass. One reason was ventricular fibrillation when guidewire passed the PmVSD, another was device dislocation, and others were the guidewire cannot pass through the PmVSD.

CONCLUSIONS

PmVSDs closure using a concentric occluder via a left parasternal ultra-minimal trans intercostal incision under TEE guidance is feasible, safe, and effective in children. This approach can be considered as an alternative treatment to open-heart surgery for restrictive PmVSDs.

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.

Percutaneous Closure of Ventricular Septal Defects in 116 Patients: Experience with different devices

Objectives

This study aimed to review the experience with percutaneous closure of ventricular septal defects (VSDs) at the National Heart Center (NHC) in Muscat, Oman.

Methods

This retrospective study was conducted from November 2008 to December 2017. Patients’ electronic medical records were reviewed to identify their clinical, imaging and interventional data before and after the procedure and on the last follow-up.

Results

A total of 116 patients, the majority of which were female (58%), underwent 118 percutaneous procedures for VSD closure at a median age of 3.54 years (range: 0.25–33 years) and a median weight of 12 kg (range: 3.5–78 kg). The mean diameter of the VSDs as determined by transoesophageal echocardiogram was 5.6 ± 1.9 mm (n = 105). The commonest type of VSD was perimembranous (n = 75, 63.5%). Devices were successfully placed during 111 (94.1%) procedures in 109 (94.0%) patients, with the commonest device being a Amplatzer™ duct occluder I (St. Jude Medical, Little Canada, Minnesota, USA; n = 39, 35.1%). There was no mortality. Early major cardiac complications occurred in six patients (5.5%) with device embolisation being the commonest (n = 4, 3.7%). The median follow-up period was 19 months (range: 1–84 months) in 89 (81.7%) of the patients. One patient (0.9%) required a permanent pacemaker for a complete heart block.

Conclusion

This study has demonstrated a good rate of VSD closure with low morbidity and no mortality using the percutaneous approach with different devices. Long-term follow-up is needed to specifically evaluate the function of adjacent structures and the long-term effects on conduction systems.

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.

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.

Percutaneous Ventricular Septal Defect Closure in Patients Under 1 Year of Age

Untreated ventricular septal defect (VSD) is an important cause of congestive heart failure in early infancy. Growth is impaired in this population, and surgical closure is challenging because of congestion in the lungs, making infants prone to respiratory infection, and because of their poor nutritional status. The aim of this study is to share our experience with percutaneous VSD closure in patients under 1 year of age. Patients with hemodynamically significant left-to-right shunt, less than 1 year of age, and with VSD diameter ≤ 6 mm were retrospectively included in the study between December 2014 and January 2017. The median length of follow-up was 8.5 (4-14.2) months. Twelve patients from 2 to 12 months of age, with a median weight of 6.75 (5.4-8) kg, were included. The mean VSD diameter as measured by angiography from the left ventricle side was 4.7 ± 0.25 mm, and from the right ventricle side was 3.4 ± 1.1 mm. All were of a perimembranous type except three, which were muscular. All defects were closed with the Amplatzer Duct Occluder II (ADO II) or the ADO II-additional size. The mean fluoroscopy duration and total radiation dose were 22.6 ± 18.7 min and 1674 ± 851 cGy/min, respectively. No aortic regurgitation associated with device closure was seen in any of the patients. Complete atrioventricular block occurred in one patient 6 months after the procedure, and was treated with a permanent pacemaker. VSD closure is challenging, regardless of whether a surgical or percutaneous procedure is used. The risks are higher for children younger than 1 year with low body weight. Percutaneous closure, which carries similar risks but is less invasive than surgery, may be the preferred alternative in early infancy.

Utilizing Hybrid Techniques to Maximize Clinical Outcomes in Congenital Heart Disease

PURPOSE OF REVIEW

The past couple of decades have brought tremendous advances to the field of pediatric and adult congenital cardiology. Recent collaborations between interventional cardiologists and cardiac surgeons have sparked novel innovative hybrid procedures that provide potentially safer, faster, and less invasive alternatives to the management of many diseases. This paper will review the most recent advances in hybrid interventions in the field of pediatric and adult congenital cardiology.

RECENT FINDINGS

The earliest experiences with hybrid interventions included intraoperative stenting of pulmonary arteries and perventricular device closure of ventricular septal defects. Newer hybrid interventions have focused on a hybrid approach to stage 1 palliation for infants with hypoplastic left heart syndrome and hybrid approaches to transcatheter pulmonary valve replacement in patients of all ages. Hybrid approaches to complex congenital heart disease are important in the management of congenital heart disease offering a less invasive approach, and novel hybrid procedures will likely be a focus of future research in this field.

Transverse Sternal Split: a Safe Mini-invasive Approach for Perventricular Device Closure of Ventricular Septal Defect

Objective

Perventricular device closure of ventricular septal defect through midline sternotomy avoids the cardiopulmonary bypass, however, lacks the cosmetic advantage. Perventricular device closure of ventricular septal defect with transverse split sternotomy was performed to add the cosmetic advantage of mini-invasive technique.

Methods

Thirty-six pediatric patients with mean age 7.14±3.24 months and weight 5.00±0.88 kg were operated for perventricular device closure of ventricular septal defect through transverse split sternotomy in 4^th intercostal space under transesophageal echocardiography guidance. In case of failure or complication, surgical closure of ventricular septal defect was performed through the same incision with cervical cannulation of common carotid artery and internal jugular vein for commencement of cardiopulmonary bypass. All the patients were postoperatively followed, and then discharged from hospital due to their surgical outcome, morbidity and mortality.

Results

Procedure was successful in 35 patients. Two patients developed transient heart block. Surgical closure of ventricular septal defect was required in one patient. Mean duration of ventilation was 11.83±3.63 hours. Mean intensive care unit and hospital stay were 1.88±0.74 days and 6.58±1.38 days, respectively. There was no in-hospital mortality. A patient died one day after hospital discharge due to arrhythmia. No patients developed wound related, vascular or neurological complication. In a mean follow-up period of 23.3±18.45 months, all 35 patients were doing well without residual defect with regression of pulmonary artery hypertension as seen on transthoracic echocardiography.

Conclusion

Transverse split sternotomy incision is a safe and effective alternative to a median sternotomy for perventricular device closure of ventricular septal defect with combined advantage of better cosmetic outcomes and avoidance of cardiopulmonary bypass.

Acute and midterm results following perventricular device closure of muscular ventricular septal defects: A multicenter PICES investigation

OBJECTIVES

To describe acute and mid-term results of hybrid perventricular device closure of muscular ventricular septal defects (mVSDs).

BACKGROUND

Perventricular device closure of mVSDs can mitigate technical limitations of percutaneous closure and need for cardiopulmonary bypass or ventriculotomy with a surgical approach.

METHODS

This is a multicenter retrospective cohort study of patients undergoing hybrid perventricular mVSD device closure from 1/2004 to 1/2014. Procedural details, adverse events, outcomes, and follow-up data were collected. Patients were divided into two groups: (1) simple (mVSD closure alone) and (2) complex (mVSD closure with concomitant cardiac surgery).

RESULTS

Forty-seven patients (60% female) underwent perventricular mVSD device closure at a median age of 5.2 months (IQR 1.8-8.9) and weight of 5.1 kg (IQR 4.0-6.9). Procedural success was 91% [100% (n = 22) simple and 84% (n = 21/25) complex]. Adverse events occurred in 19% (9/47) [9% (2/22) simple and 28% (7/25) complex]. Hospital length of stay (LOS) was shorter in the simple vs. complex group (4 vs. 14 days, P < 0.01). At mid-term follow-up of 19.2 months (IQR 2.3-43) 90% of pts had complete mVSD closure; none developed late heart block, increased atrioventricular (AV) valve insufficiency or ventricular dysfunction.

CONCLUSIONS

Perventricular device closure of simple mVSD was associated with a high rate of procedural success, few adverse events, and short hospital LOS. Procedural adverse events were associated with the presence of concomitant complex surgery. Residual mVSD, AV valve insufficiency, or ventricular dysfunction were uncommon at mid-term follow-up. © 2017 Wiley Periodicals, Inc.

Interventional VSD-Closure with the Nit-Occlud® Lê VSD-Coil in 110 Patients: Early and Midterm Results of the EUREVECO-Registry

In August 2010, the Nit-Occlud^® Lê (EUREVECO) became available for transcatheter coil occlusion of ventricular septal defects (VSDs). Retrospective European Registry for VSD Closure using the Nit-Occlud^® Lê-VSD-Coil; analysis of the feasibility, results, safety and follow-up of VSD-closure over a 3-year period in 18 European centers. In 102 of 111 patients (female 66), successful VSD closure was performed (mean age 8.2 years, mean weight 28.82 kg), 81 perimembranous VSDs (48 with aneurysm), 30 muscular VSDs, mean procedure time was 121.1 min, and mean fluoroscopy time was 26.3 min. Short- and midterm term follow-up was possible in 100/102 patients, there was 1 embolization and 1 explantation after 24 months. Immediate complete closure occurred in 49 of 101 patients (48.5%), trivial residual shunt was present in 51 (50.0%), closure rate was 95% after 6 months and 97% after 1 year. Out of the 102 patients, there were 2 severe complications (1.8%) (1 severe hemolysis, 1 embolization) and 8 moderate/transient (=7.2%) including 1 transient AV block. During a mean follow-up period of 31.3 months (range 24-48) and a total follow-up time of 224.75 patient years, no further problems occurred. VSD closure with the Nit-Occlud^® Lê VSD coil is feasible and safe with a minimal risk of severe side effects. The long-term effects and safety require further clinical follow-up studies.

Iatrogenic embolization and transcatheter retrieval of a ventricular septal defect occluder in a dog

A 7-month-old Irish Setter underwent transcatheter therapy of a muscular ventricular septal defect (VSD) and pulmonary valve stenosis. Standard devices for muscular VSD closure could not span the interventricular septum due to right ventricular hypertrophy, and an Amplatzer post-infarction muscular VSD occluder with a wider waist was successfully implanted. Following VSD closure, inflation of the balloon dilation catheter during balloon pulmonary valvuloplasty resulted in iatrogenic embolization of the VSD occluder to the left ventricular outflow tract. Retrieval and reimplantation of the device was achieved using a snare catheter. This report describes a potential complication and management during intracardiac device implantation in a dog. Additionally, the case illustrates that the Amplatzer post-infarction muscular VSD occluder holds potential value in animals with a hypertrophied interventricular septum that cannot be spanned using a conventional device.

Left ventricular pseudoaneurysm after perventricular ventricular septal defect device closure

Perventricular ventricular septal defect (VSD) closure has been adopted as a therapeutic option for selected patients with muscular VSDs. This technique may combine some of the advantages of surgical and interventional techniques. Complication rates have been low: only one case of procedure-related left ventricular (LV) pseudoaneurysm has been documented. We report the surgical repair for a LV pseudoaneurysm after perventricular VSD device closure.

Perventricular closure of muscular ventricular septal defects in infants with echocardiographic guidance only

OBJECTIVE

To report our experience with perventricular closure of muscular (apical) ventricular septal defects (VSDs) in small infants, with echocardiographic guidance only, in a nonhybrid suite.

METHODS

Eight infants with nine large muscular (apical) VSDs underwent perventricular device closure in a nonhybrid operating room, with transesophageal and epicardial echocardiography guidance, at a mean age and weight of 3.07 (0.3-7.28) months and 3.7 (2.5-6.2) kg, respectively. Five patients had multiple VSDs. Four had associated cardiac defects.

RESULTS

Nine Amplatzer muscular VSD devices with a mean size of 10 (4-14) mm were deployed. Seven patients were discharged from the intensive care unit with a mean length of stay of 8.6 days. Four patients had minimal postprocedural residual shunt; no one had a residual shunt at six-month follow-up. Mid-term results are excellent.

CONCLUSION

Perventricular closure is feasible under echocardiographic guidance only in small patients, even without hybrid suite. This may be a good approach for very symptomatic low-weight infants with apical VSD and may also be useful, in any center, at any time, and in any operating room, to treat an associated apical VSD, even unexpected.

Techniques and results in the management of multiple muscular trabecular ventricular septal defects

The management of patients with multiple muscular trabecular ventricular septal defects (VSDs) remains controversial. In the past two decades, innovative techniques including a right ventricular apical infundibulotomy and transcatheter, intraoperative and perventricular device closure have been exploited, and essential right atrial approach and limited apical left ventriculotomy have also been refined. However, specific management guidelines for this difficult disease have not been established. In this article, the benefits and drawbacks of each technique are reviewed and discussed. Primary repair for infants with multiple muscular trabecular VSDs was associated with good late outcomes. The right atrial approach was satisfactory for all muscular VSDs, excluding apical defects that were well seen through a limited apical ventriculotomy. Surgical closure of apical defects could be achieved safely and completely in early infancy through a limited apical left ventriculotomy or a right ventricular apical infundibulotomy. Further follow-up and prudent evaluations of ventriculotomy-associated morbidities are needed. Pulmonary artery banding should be limited to a small infant with complex associated defects. Percutaneous device closure, the most desirable option, is impractical due to limitations between the delivery system and access route. Intraoperative device closure appears less successful than device closure in the catheterization laboratory. Perventricular device closure has a significant advantage of being a non-bypass procedure approach. A less invasive strategy for "true" Swiss cheese septum is needed. All may have an important role, and results obtained by using these techniques are encouraging. These hybrid approaches will promise future success on management guidelines of multiple muscular trabecular VSDs.

Minimally invasive perventricular device closure of ventricular septal defect in infants under transthoracic echocardiograhic guidance: feasibility and comparison with transesophageal echocardiography

BACKGROUND

A hybrid approach to minimally invasive perventricular closure of VSD in infants is safe and effective, and has been performed under guidance of transesophageal echocardiography (TEE). We applied transthoracic echocardiographic (TTE) guidance to this hybrid approach, and compare results guided by TTE with those by TEE.

METHODS

From January 2011 to January 2012, 71 infants with VSD were enrolled to undergo a minimally invasive device closure. After evaluation of VSD by TTE, either TEE or TTE was used to guide the minimally invasive device closure. 30 patients had TEE guidance, and 41 patients had TTE. All patients were followed for 3 months after the operation.

RESULTS

The TEE group had a success rate of 93.3% (28/30) for device implantation, compared with 92.7% (38/41) in the TTE group. Two patients in the TEE group turned to surgical closure, one for involvement of the inlet area of VSD demonstrated by TEE, another for moderate aortic regurgitation after device implantation. Two patients in the TTE group also transferred to surgical closure, one for residual shunt, another for failure of the floppy wire across the defect. In addition, one patient in the TTE group experienced dropout of the occluder one day postoperatively. At 3-month follow-up, one patient had mild aortic regurgitation in the TEE group and in two patients in the TTE group. There were no episodes of cardiac block, thromboembolism, or device displacement in either group.

CONCLUSIONS

TTE-guided VSD closure is feasible in infants, with results similar to those of TEE guidance, although caution is advisable.

Long-term complications following surgical patch closure of multiple muscular ventricular septal defects

BACKGROUND

Multiple muscular ventricular septal defects (VSDs) in children can be difficult to treat and a range of techniques has been advocated. These include pulmonary artery banding, interventional catheter closure, and a variety of surgical approaches. When there are apical muscular defects and associated coarse trabeculations in the right ventricle (RV) producing a "Swiss cheese" pattern, a large patch extending on to the RV free wall and excluding part of the apex has been used.

METHODS

We assessed four adult patients who had surgery 22 to 45 years ago to treat muscular VSD by patches which excluded the RV apex.

RESULTS

Ages ranged from 22 to 50 years. Re-presentations were for polycythemia, cyanosis, syncope, and atrial flutter. Echocardiography showed bidirectional flow from left ventricle to apex of RV, no pulmonary hypertension, small-sized RV with diastolic dysfunction, enlarged right atria, reopening of patent foramen ovale (PFO) in three, and positive bubble studies with right to left shunting in two. Catheterization confirmed elevated right atrial and RV end diastolic pressures. Two patients had evidence of hepatic cirrhosis. One woman had device closure of PFO, but has right heart failure. One man had redo surgical closure of VSD and PFO. Another patient is being considered for a Glenn shunt to take some load off RV.

CONCLUSIONS

Surgical closure of muscular VSD by large patch with RV apical exclusion gives good early results. However, long term in adult life, the reduced size of RV, and diastolic dysfunction cause problems. These include reopening of PFO with cyanosis, right heart failure, cirrhosis, and arrhythmias.

Perventricular device closure of isolated muscular ventricular septal defect in infants: a single centre experience

OBJECTIVES

To evaluate prospective single centre experience of mid-term safety and efficacy of perventricular device closure of isolated large muscular ventricular septal defect (mVSD) in high-risk infants.

BACKGROUND

Surgical closures of large mVSD in infants represent a challenge with significant morbidity.

METHODS

Between August 2008-2010, perventricular closure was attempted in 24 infants of 6.01 ± 2.37 months age and 4.27 ± 0.56 kg weight under TEE guidance.

RESULTS

The device was successfully deployed in 21/24 infants. Size of mVSD was 8.42 ± 1.46 mm (6.1-12 mm). Mean procedure time was 28.8 ± 11.7 min. The closure rate was 84% immediately and 100% at 6 months. Four patients suffered major complications: 2-died, 1-esophageal perforation, 1-persistent CHB. At 26.23 ± 6.63 months follow-up two patients were symptomatic: 1-required device retrieval, 1-died of severe gastroenteritis.

CONCLUSION

Perventricular device closure of isolated mVSD appears feasible option at mid-term follow-up and may either substitute or complement the conventional surgical technique in selected cases depending on institutional paediatric cardiac surgery performance.

Transthoracic echocardiographic guidance of minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass: initial experience

BACKGROUND

Our purpose was to investigate the feasibility of transthoracic echocardiographic (TTE) guidance for minimally invasive periventricular device closure of perimembranous ventricular septal defects (VSDs).

METHODS

From June 2011 to September 2011, we enrolled 18 young children with perimembranous VSDs to receive minimally invasive device closure in our hospital. All of the patients were examined by TTE to determine the VSD morphology, diameter, and rims. During intra-operative device closure, real-time bedside TTE alone was used to guide device implantation.

RESULTS

Device implantation using TTE guidance was successful in 16 patients. Symmetric devices were used in 14 patients, and asymmetric devices were used in 2 patients. Only one patient experienced mild aortic regurgitation, and there were no instances of residual shunt, significant arrhythmias, thromboembolism, or device displacement. Two patients were transferred to surgical closure, one due to residual shunting and the other as a result of unsuccessful wire penetration of the VSD gap.

CONCLUSIONS

Our data indicate that TTE-guided VSD closure is feasible in young children, although a longer follow-up may be needed to document the long-term success.

Intracoronary transplantation of genetically modified mesenchymal stem cells, a novel method to close muscular ventricular septal defects

Muscular ventricular septal defects remain a challenge despite the progress in surgical and interventional closure of ventricular septal defects. Our hypothesis was inspired by the fact that more than two thirds of children with muscular ventricular septal defects experienced spontaneous closure. Therefore, we intend to induce the spontaneous closure of muscular ventricular septal defects by means of targeted intracoronary injection of mesenchymal stem cells which are genetically modified to enhance myocardial hypertrophy. The transplantation of bone marrow derived cells has been observed to be effective in improving tissue recovery and ameliorating cardiac function in patients and animal models with ischemic heart disease, acute myocarditis and dilated cardiomyopathy. We expect that the targeted intracoronary transplantation of genetically modified mesenchymal stem cells could enhance the tissue generation and myocardial hypertrophy simultaneously, which may lead to the closure of muscular ventricular septal defects in a way that imitate the spontaneous closure of ventricular septal defects.

Hybrid management of a large atrial septal defect and a patent ductus arteriosus in an infant with chronic lung disease

We report a case wherein a dysmorphic four-month-old infant (weighing 4.5 kgs) with an 8 mm atrial septal defect (ASD), a 1.5 mm patent ductus arteriosus (PDA), a 2 mm mid-muscular ventricular septal defect (VSD) associated with chronic lung disease, and severe pulmonary hypertension, was successfully managed using a hybrid approach, without the use of cardiopulmonary bypass (CPB). Through a median sternotomy, the PDA was ligated and the ASD was closed with a 9 mm Amplatzer septal occluder implanted through peratrial access. The VSD was left untouched. Serial echocardiograms showed complete closure of the ASD and PDA, with progressive normalization of the pulmonary artery (PA) pressures within three months. The child rapidly gained weight and was weaned from sildenafil and oxygen administration. After 12 months, the VSD closed spontaneously and the child remained well, with normal PA pressures. A hybrid approach without the use of CPB should be considered in the management of infants with congenital heart disease, associated with chronic lung disease and pulmonary hypertension.

Perventricular device closure of congenital muscular ventricular septal defects

Muscular ventricular septal defects (MVSDs) account for approximately 20% of all congenital ventricular septal defects. Large defects in infants result in early heart failure, failure to thrive and pulmonary hypertension. Although percutaneous closure of MVSDs has been employed safely and effectively in children, adolescents and adults, its application in the small infant (weight <6 kg) carries a higher risk for complications including arrhythmias, hemodynamic compromise, cardiac perforation, tamponade and death. Perventricular closure of such defects, introduced by Amin and coworkers in the late 1990s, has become an attractive treatment modality for these small and high-risk patients. Experience worldwide has shown that the procedure is feasible, reproducible, safe and effective. In this article, the authors review the indications, the step-by-step technique and the results of perventricular closure of MVSDs using the AMPLATZER mVSD device (AGA Medical, MN, USA).

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

OBJECTIVES

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Percutaneous treatment of atrial septal defects, muscular ventricular septal defects and patent ductus arteriosus in infants under one year of age

Amplatzer devices are used for the percutaneous closure of ostium secundum atrial septal defects, muscular ventricular septal defects and patent ductus arteriosus. However, very little experience has been gained in using these devices in infants under 1 year of age. Between January 2001 and January 2008, 22 symptomatic infants aged under 1 year underwent percutaneous treatment: three had an ostium secundum atrial septal defect, 15 had patent ductus arteriosus, and four had a muscular ventricular septal defect. All the procedures were completed successfully. No immediate or medium-term complications were observed. Closure of these types of defect using an Amplatzer device in infants under 1 year of age, who would otherwise require surgery, is a safe and effective procedure.

[Update on pediatric cardiology and congenital heart disease]

The fields of pediatric cardiology and congenital heart disease have experienced considerable progress in the last few years, with advances in new diagnostic and therapeutic techniques that can be applied at all stages of life from the fetus to the adult. This article reviews scientific publications in a number of areas that appeared between August 2007 and September 2008. In developed countries, congenital heart disease is becoming increasingly prevalent in nonpediatric patients, including pregnant women. Actions aimed at preventing coronary heart disease must be started early in infancy and should involve the promotion of a healthy diet and lifestyle. Recent developments in echocardiography include the introduction of three-dimensional echocardiography and of new techniques such as two-dimensional speckle tracking imaging, which can be used for both anatomical and functional investigations in patients with complex heart disease, including a univentricular heart. Progress has also occurred in fetal cardiology, with new data on prognosis and prognostic factors and developments in intrauterine interventions, though indications for these interventions have still to be established. Heart transplantation has become a routine procedure, supplemented in some cases by circulatory support devices. In catheter interventions, new devices have become available for the closure of atrial or ventricular septal defects and patent ductus arteriosus as well as for percutaneous pulmonary valve implantation. Surgery is also advancing, in some cases with hybrid techniques, particularly for the treatment of hypoplastic left heart syndrome. The article ends with a review of publications on cardiomyopathy, myocarditis and the treatment of bacterial endocarditis.