Transcatheter closure of postsurgical residual ventricular septal defects: Early and mid-term results

Long-term outcomes of percutaneous closure of ventricular septal defects in children using different devices: A single centre experience from Egypt

BACKGROUND

The feasibility of percutaneous closure ventricular septal defects (VSD) in children has been previously proven. However, data on long-term outcomes are limited. We aim to evaluate the long-term outcome of our experience with percutaneous closure of VSD using various occluders.

METHODS

Retrospective institutional analysis of children who underwent transcatheter closure of perimembranous and muscular VSDs between September 2012 and February 2020. Patient demographics, procedural, and long-term follow-up data were comprehensively analyzed. Patients who lost to follow-up within two years post-procedure were excluded.

RESULTS

We identified 75 patients (54.7% males) with a median of 66 months (IQR, 46-96). The closure success rate at one year was 95.7%. Complete heart block was detected in two patients early post-procedure and resolved with steroids. The VSDs were perimembranous (52%), muscular (33.33%), and residual (14.67%). Implanted devices were Pfm Nit-Occlud LeˆVSD Coil (42.7%), Hyperion^TM VSD Muscular Occluder (28%), Amplatzer VSD muscular occluder (10.7%), Amplatzer Duct Occluder (14.7%), Occlutech Muscular VSD Occluder (2.7%), and Amplatzer Duct Occluder II (1.3%). No new arrhythmia or valve regurgitation was detected after two years post-procedure. Persisted complications on long-term follow-up included: residual shunting in 3(4%), mild tricuspid regurgitation in 2(2.7%), and aortic regurgitation in 2(2.7%), with one immediate post-catheterization mild aortic regurgitation worsened during follow-up, requiring surgical repair of VSD three years after device implantation. No deaths were reported.

CONCLUSION

Long-term outcomes of pediatric transcatheter VSD closure using different devices are satisfactory. Post-procedural adverse events are limited, but long-term surveillance is necessary to monitor their progression.

Transcatheter Closure of Residual and Iatrogenic Ventricular Septal Defects: Tertiary Center Experience and Outcome

Residual or iatrogenic ventricular septal defects (VSDs) may result in significant hemodynamic effect. This study aimed to review our center experience in transcatheter closure of post-surgical and post-intervention residual and iatrogenic VSDs and to report on their 12-month long-term outcome. All patients who underwent transcatheter closure of residual/iatrogenic VSDs after surgical or transcatheter CHD interventions between January-2015 and January-2020 were included. Patients' medical records were reviewed and analyzed. Twenty-three patients with a mean age of 14.3 ± 8.8 years were included. The VSD was residual in 18 (78.3%) patients and iatrogenic in 5 (21.7%) patients, post-operative in 19 (82.6%) patients and post-transcatheter in 4 (17.4%) patients. The VSD site was peri-membranous in 9 (39.1%) patients, high-muscular in 6 (26.1%) patients, mid-muscular in 4 (17.4%) patients, and Gerbode shunt in 4 (17.4%) patients. The QP/QS ratio was 2.5 ± 0.7, and the VSD diameter was 6.1 ± 2.1 mm. Most, 16 (71.43%) patients underwent antegrade device deployment, and 7 (28.57%) patients underwent retrograde transaortic device deployment with 3 (13.0%) patients required two devices. Amplatzer™ Muscular VSD devices were used in 16 (69.6%) patients, Amplatzer™ Duct occlude-I devices were used in 4 (17.4%) patients, and Amplatzer™ Duct Occluder-II devices were used in 3 (13.0%) patients with a mean device size of 8.8 ± 2.8 mm. Procedural and fluoroscopy times were 55.1 ± 16.2 and 16.3 ± 4.0 min respectively. During follow-up (23.3 ± 15.9 months), no patient required re-intervention or exhibited mortality. Transcatheter closure of post-operative and post-intervention residual/iatrogenic VSDs represents a safe, feasible, and effective therapeutic approach.

Long-term surgical outcomes after repair of multiple ventricular septal defects in pediatrics

Background

Surgical closure of multiple ventricular septal defects (VSDs) is challenging and associated with a high complication rate. Several factors may affect the outcomes after surgical repair of multiple VSDs. We aimed to report the outcomes after surgical repair of multiple VSDs before and after 1 year and identify the factors affecting the outcomes. We have studied forty-eight patients between 2016 and 2017 who had surgical repair of multiple VSDs. We grouped them according to the age at the time of repair. Study outcomes were hospital complications, prolonged hospital stay, and reoperation.

Results

There were 18 females (60%) in group 1 and 13 (72.22%) in group 2 (P = 0.39). There were no differences in the operative outcomes between the groups. Prolonged postoperative stay was associated with group 1 (OR 0.23 (0.055–0.96); P = 0.04) and lower body weight (OR 0.76 (0.59–0.97); P = 0.03). Hospital mortality occurred in 2 patients (6.67%) in group 1 and 1 patient (5.56%) in group 2 (P > 0.99). Five patients had reoperations: two for residual VSDs, two for subaortic membrane resection, and one for epicardial pacemaker implantation. All reoperations occurred in group 1 (log-rank P = 0.08). Two patients had transcatheter closure of the residual muscular VSDs; both were in group 2.

Conclusions

Surgical repair of multiple VSDs was associated with good hospital outcomes. The outcomes were comparable in patients younger or older than 1 year of age. Young age at repair could lead to prolonged postoperative stay and a higher reoperation rate.

Effect of transcatheter closure by AmplatzerTM Duct Occluder II in patients with small ventricular septal defect

Transcatheter closure of ventricular septal defect (VSD) is an alternative treatment of surgery. However, because of the potential risk of the complete atrioventricular block (AVB) and the lack of available dedicated devices for VSD, this procedure rarely used most centers. Recently in Thailand, with distinct device design that may cause less clamp force and radial force, the Amplatzer^TMDuct Occluder (ADO) II has become available for the closure of small VSDs. This is a retrospective review of 49 patients who underwent transcatheter VSD closure using ADO II at Songklanagarind hospital and Queen Sirikit National Institute of Child Health between January 2014 and December 2016 with an intention to report procedural success rate and 12-months-outcomes. Twenty-six cases were female. The median age and weight at treatment were 7.8 year (ranged from 1.9 to 25 year) and 25.1 kg (ranged from 11 and 57 kg). The majority (65.3%) of the VSD was a perimembranous defect. The mean diameter of LV entry was 5.2 ± 2.5 mm and the mean RV exit was 3.2 ± 0.8 mm. Four patients had more than 1 exit at RV orifice. The mean length of the VSD was 5.3 ± 1.8 mm. The mean aortic valve-VSD distance was 3.9 ± 2.0 mm. The mean tricuspid valve-VSD distance was 3.8 ± 2.5 mm. The procedural success achieved in all patients (100%), most of the implantations were performed in a retrograde approach (53.1%). The ADO II was successfully implanted in 2 cases (5%) who failed other devices in the first attempts. There were no major complications. There were no changes in the severity of tricuspid and aortic valve regurgitation immediate after implantation and at 12 months' follow-up. Three patients (6%) had tiny to small residual shunt at 12 months' follow-up. None of the patients had a complete heart block. However, new-onset of left bundle branch block and right bundle branch block occurred in 2 (5%) cases and 5 (10%) cases, respectively. With symmetrical double-disc design and softness of the device, the ADO II can be safely and effectively used for closure of the VSDs with the defect size less than 6 mm.

The experience of transcatheter closure of postoperative ventricular septal defect after total correction

BACKGROUND

The purpose of this study was to describe our experience with patients who underwent transcatheter closure of a post-operative ventricular septal defect (VSD).

METHODS

All patients who underwent transcatheter closure of a VSD after total correction of congenital heart disease since 2012 were enrolled. Medical records were retrospectively reviewed to determine the patients' initial diagnosis, closure device used, and final outcome after device closure.

RESULTS

Six patients with a median age of 17.7 years (range: 7 months-48 years) underwent transcatheter closure of an unresolved VSD. The median time interval from the initial corrective surgery to the percutaneous closure procedure was 10.4 years (range: 0.3-33.0 years). The initial diagnoses included tetralogy of Fallot (one patient), VSD (two patients), double outlet of the right ventricle (two patients), and aortic valve stenosis (one patient). The reasons for unresolved VSD (other than leakage) after corrective surgery included previous fenestration (in two patients), and iatrogenic Gerbode shunt (in one patient). Various devices were used, including the Amplatzer duct occluder I, Amplatzer duct occluder II, Amplatzer vascular plug II, and Cocoon membranous VSD occluder. Only one device was used in each patient. There were no major complications associated with the closure procedures. The immediate results were satisfactory. The median follow-up duration was 2.75 years. All cases were successful, with the exception of minimal leak in one patient.

CONCLUSIONS

Transcatheter device closure of post-operative VSD can be performed using various device types of devices and is safe and effective. But more experiences are mandatory.

Transcatheter Closure Versus Repeat Surgery for the Treatment of Postoperative Left-to-Right Shunts: A Single Center 15-Year Experience

Background

Repeat surgery and the percutaneous approach (transcatheter closure (TCC)) have been used for the management of postoperative left-to-right shunts. In this study, we described our 15 years of experience in treating postoperative left-to-right shunts with these two approaches.

Methods

From February 2002 to February 2017, 50 patients with residual left-to-right shunts, following cardiac surgery, were treated using TCC or repeat surgery. Clinical examination, standard 12-lead electrocardiography, chest X-ray, and a transthoracic echocardiogram were performed before hospital discharge and at all follow-ups.

Results

The closure rate was 100% in both groups and there was no procedure-related mortality. Patients with TCC had few complications. The procedure time and duration of hospital stay for TCC patients were 58.9 ± 27.7 min and 6.1 ± 0.8 days, respectively. Eleven out of 19 patients receiving reoperation suffered serious complications after surgery, e.g., bleeding and nosocomial infections. The operation time and duration of hospital stay for reoperation patients were 256.7 ± 60.5 min and 17.0 ± 4.0 days, respectively. No other serious complications were seen at all follow-up visits for both groups.

Conclusions

In conclusions, TCC is safe and effective for the management of postoperative left-to-right shunts, and is associated with few complications, which can be the favored closure strategy over repeat surgery for the management of postoperative left-to-right shunts.

Clinical Experience of Transcatheter Closure for Residual Ventricular Septal Defect in Pediatric Patients

BACKGROUND

Open cardiac surgery has traditionally been the gold standard for repair of ventricular septal defect (VSD). The inherent risks and complications associated with open surgery and the incidence of postoperative residual VSD are significant disadvantages of the open surgical approach.

OBJECTIVE

To evaluate the methodology and efficacy of transcatheter closure of postoperative residual VSD in children.

METHODS

Patients with postoperative VSD who underwent percutaneous device closure in the period from August 2010 and February 2014 in our center were analyzed retrospectively. Twelve children, including 8 males and 4 females, with mean age of 8.13 ± 5.39 years (range 0.67-17 years) and mean weight of 29.63 ± 20.86 kg (range 5.5-66 kg) were included in the study.

RESULTS

Ten cases had residual shunts situated at the margin of the patches while the other two had residual shunts because of multiple muscular VSD. The mean VSD diameter was 3.84 ± 1.86 mm (range 2.3-8.7 mm). On cardiac catheterization, the reported mean pulmonary circulatory blood volume/systemic circulation volume (Qp/Qs) ratio was 1.86 ± 0.91 (range 1.1-4.25) and the mean pulmonary artery pressure was 25.92 ± 12.42 mm Hg (range 7-52 mm Hg). Successful transcatheter closure was obtained in all twelve patients with postsurgery residual VSD. Two cases with residual muscular VSD underwent retrograde catheterization via the femoral artery while one case with residual VSD located at the lower margin of the patch was accessed via the internal jugular vein. The mean procedure time was 81.25 ± 25.86 minutes (range 40-120 minutes). There was no evidence of residual VSD, and no instances of new-onset valvular regurgitation were reported, with the only two exceptions being patients who had multiple muscular VSDs where clinically insignificant residual shunts were detected.

CONCLUSION

Our retrospective study highlights the potential safety and therapeutic efficacy of transcatheter approach for closing postoperative residual VSD in children.

RECOMMENDATIONS

More robust studies with longer-term follow-up of outcomes are required to firmly establish the safety profile and respective indications for use of various occluder devices for treating different categories of residual VSD.

Muscular ventricular septal defect in a newborn with truncus arteriosus communis: perventricular transcatheter closure under echocardiographic guidance only, a case report

We report a case of a 3.5-kg newborn presenting with a muscular ventricular septal defect (VSD) in the setting of truncus arteriosus communis (common arterial trunk). Reparative surgery using a hybrid approach included perventricular closure of the muscular VSD on the beating heart.

Transesophageal echocardiography-guided minimally invasive surgical device closure of an unusually shaped residual ventricular septal defect in a child

Closure of residual ventricular septal defect with an occluder is traditionally performed by a percutaneous transcatheter approach under radiographic guidance. However, this procedure may be of limited use in cases with unusually shaped defects and in patients with low body weight. Here, we report minimally invasive surgical device closure of a 6 mm residual ventricular septal defect under transesophageal echocardiographic guidance, in a patient weighing 10 kg that had previously undergone surgical correction of a double outlet right ventricle. The defect was positioned in the suture line between the Gore-Tex vascular graft and the remnant ventricular septum, and was unusual in that it formed a 135° angle with the Gore-Tex graft. The defect was closed successfully with a 10 mm asymmetric occluder. To the best of our knowledge, this is the first report of transesophageal echocardiography-guided minimally invasive surgical device closure of an unusually shaped residual ventricular septal defect after surgical correction of a double-outlet right ventricle.

Transcatheter closure of ventricular septal defects with nitinol wire occluders of type patent ductus arteriosus

Ventricular septal defects closure (VSD) depending on the anatomy and clinical setting can be performed surgically or by a hybrid and transcatheter approach. Two cases of children with VSD will be presented. Patients’ defects were closed with various types of occluders made of nitinol wire mesh occluder, patent ductus arteriosus (PDA) type. The first case was a 2.5-year-old boy after cardiosurgical correction of tetralogy of Fallot (TOF). After the procedure, a significant haemodynamic residual VSD was observed, which was not successfully closed during the subsequent reoperation. Despite pharmacological treatment, symptoms of heart failure were observed in this patient. In echocardiographic images the residual VSD was presented as a tunnel-like dissection of the ventricular septum (length 6 mm and diameter 3.4 mm). The defect was closed via arterial access with an Amplatzer Duct Occluder II (ADO II). The procedure was successfully performed without any medical complications. In this child, a significant shunt reduction and a noticeable improvement in the patient's clinical status and diminished symptoms of heart failure were noticed. The second patient was a 4-year-old girl suffering from a multi-perforated perimembranous VSD accompanied by a ventricular septal defect with aneurysm. The defect was closed by a venous approach with a PDA Cardio-O-Fix occluder (very similar to ADO I). No short-term or long-term complications were visible during or after the procedure. Only a mild residual shunt through the VSD was observed 6 months afterwards. Transcatheter VSD closure with a proper morphology, with occluders of type Amplatzer Duct Occluder ADO I or ADO II, constitutes a safe and effective therapeutic alternative.

Closed-chest transthoracic magnetic resonance imaging-guided ventricular septal defect closure in swine

OBJECTIVES

The aim of this study was to close ventricular septal defects (VSDs) directly through the chest wall using magnetic resonance imaging (MRI) guidance, without cardiopulmonary bypass, sternotomy, or radiation exposure.

BACKGROUND

Surgical, percutaneous, and hybrid management of VSD each have limitations and known morbidity.

METHODS

Percutaneous muscular VSDs were created in 10 naive Yorkshire swine using a transjugular laser catheter. Under real-time MRI guidance, a direct transthoracic vascular access sheath was introduced through the chest into the heart along a trajectory suitable for VSD access and closure. Through this transthoracic sheath, muscular VSDs were occluded using a commercial nitinol device. Finally, the right ventricular free wall was closed using a commercial collagen plug intended for arterial closure.

RESULTS

Anterior, posterior, and mid-muscular VSDs (6.8 ± 1.8 mm) were created. VSDs were closed successfully in all animals. The transthoracic access sheath was displaced in 2, both fatal. Thereafter, we tested an intracameral retention sheath to prevent this complication. Right ventricular access ports were closed successfully in all, and after as many as 30 days, healed successfully.

CONCLUSIONS

Real-time MRI guidance allowed closed-chest transthoracic perventricular muscular VSD closure in a clinically meaningful animal model. Once applied to patients, this approach may avoid traditional surgical, percutaneous, or open-chest transcatheter ("hybrid") risks.

Percutaneous closure of paravalvular leak and ventricular septum defect

We report a case of a patient with history of complicated infective endocarditis. Following aortic valve replacement, he developed heart failure symptoms related to paravalvular leak and ventricular septum defect. Comprehensive multimodality imaging allowed planning a simultaneous closure of both with a single device. Successfully accomplished procedure resulted in significant abatement of symptoms and reduction of ventricles dilatation.