Percutaneous device closure of congenital and iatrogenic ventricular septal defects in adult patients

Recurrent ventricular septal defect following closure CorMatrix: A case report

Ventricular septal ruptures are an uncommon complication following acute myocardial infarction. Operative repair, utilizing a patch for closure of the defect, is the primary treatment modality to achieve hemodynamic stability. The use of an extracellular matrix derived from small intestinal submucosa as a scaffold for tissue repair is becoming increasingly common. Here, we present the case of a 58-year-old female found to have a ventricular septal rupture and posterior left ventricular aneurysm following late presentation after a myocardial infarction that required operative repair with a CorMatrix patch. Upon readmission for dyspnea and poor exercise tolerance several months later, the patch was subsequently found to have near-completely reabsorbed. There is a paucity of long-term outcomes data following the use of CorMatrix for septal defects, with rare reports of such reabsorption. Further study is required to identify the incidence and implications of such findings.

Directly ventricular septal defect closure without using arteriovenous wire loop: Our adult case series using transarterial retrograde approach

Objective:

The standard transcatheter ventricular septal defects (VSD) closure procedure is established with arteriovenous (AV) loop and is called as antegrade approach. The directly retrograde transarterial VSD closure without using AV loop might be better option as shortens the procedure time and decreases radiation exposure.

Methods:

Our series consist of twelve sequential adult cases with congenital VSDs (seven with perimembranous, four with muscular, one with postoperative residuel VSD). The mean age was 26.9 (Range 18–58), the mean height was 168.75 cm (Range 155–185cm), and the mean body mass index was 23.4 (Range 17.3–28.4). Maximum and minimum defect sizes were 10 and 5 mm and the mean defect size was 6.24 mm. The procedure was performed with left heart catheterization and advancing the delivery sheath over the stiff exchange wire then VSD occlusion from left side.

Results:

The defects were successfully closed with this technique in eleven patients. In sixth patient, the defect could not be cannulated by the delivery sheath, as the tip of the sheath did not reach the defect and VSD was closed with same sheath by standard transvenous approach using AV loop. We didn’t encounter any complication releated to semilunar or atrioventricular valves. Atrioventricular conduction system was not affected by the procedure in any patients. The median procedure and fluoroscopy times were 66 and 16.5 minutes respectively.

Conclusion:

Transarterial retrograde VSD closure without using AV loop simplifies the procedure, decreases the radiation exposure, and shortens the procedure time. The only limitation in adult patients is delivery sheath length.

Transcatheter Closure of Iatrogenic VSDs after Aortic Valve Replacement Surgery: 2 Case Reports and a Literature Review

We report 2 new cases of transcatheter closure of iatrogenic ventricular septal defects after aortic valve replacement surgery, together with our finding, in a literature review, of 9 additional patients who had undergone this procedure from 2004 through 2013. In all 11 cases, transcatheter device closure was indicated for a substantial intracardiac shunt with symptomatic heart failure, and such a device was successfully deployed across the iatrogenic ventricular septal defect, with clinical improvement. Our review suggests that transcatheter closure of iatrogenic ventricular septal defects in patients with previous aortic valve replacement surgery is a safe and effective treatment option, providing anatomic defect closure and relief of symptoms in the short-to-medium term.

Posttranscatheter Aortic Valve Replacement Ventricular Septal Defect During Transfemoral Edwards SAPIEN Valve Implantation

Transcatheter aortic valve replacement (TAVR) is gaining favor as a treatment for aortic stenosis in patients at high risk for the open surgical approach. The following is a report of a 95-year-old woman with severe aortic stenosis who presented for TAVR with an Edwards SAPIEN valve. Her medical history included pacemaker-dependent complete heart block and a recent episode of congestive heart failure secondary to a non-ST segment elevation myocardial infarction. The TAVR was performed successfully through an open left femoral artery approach, and the patient was found to have a new perimembranous ventricular septal defect identified postoperatively.

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

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

Percutaneous options for heart failure in adults with congenital heart disease

In the context of congenital heart disease (CHD), the complex biochemical and physiologic response to the pressure- or volume-loaded ventricle can be induced by stenotic and shunt/regurgitant lesions, respectively. A range of transcatheter therapies have recently emerged to expand the therapeutic potential of the more traditional surgical and medical interventions for heart failure in patients with CHD. Together, these complementary interventions aim to treat the growing patient population with adult CHD (ACHD). In this article, the most commonly used transcatheter interventions for heart failure in patients with ACHD are reviewed.

Evolving trends in interventional cardiology: endovascular options for congenital disease in adults

As increasing numbers of patients with congenital heart disease enter adulthood, there is a growing need for minimally invasive percutaneous interventions, primarily to minimize the number of repeated surgeries required by these patients. The use of percutaneous devices is commonplace for the treatment of simple lesions, such as atrial septal defect, patent foramen ovale, patent duct arteriosus, and abnormal vascular connections. There is also substantial experience with device closure of membranous and muscular ventricular septal defects, as well as more complex shunts such as baffle leaks after atrial switch repair and ventricular pseudoaneurysms. An increasing use of covered stents has improved the safety of aortic coarctation, conduit, and branch pulmonary stenosis interventions. Percutaneous pulmonary valve implantation now has an established role in the setting of dysfunctional right ventricle-pulmonary artery conduits or failing bioprosthetic pulmonary valves. Many patients remain unsuitable for percutaneous pulmonary valve implantation because of large diameter "native" outflow tracts, however, various techniques have emerged and multiple devices are in development to provide solutions for these unique anatomic challenges. Hybrid approaches involving use of surgical and transcatheter techniques are increasingly common, serving to optimize efficacy and safety of certain procedures; they depend on a collaborative and collegial relationship between cardiac surgeons and interventionalists that is primarily patient-centred.

A successful percutaneous closure of ventricular septal defect following septal myectomy in patients with hypertrophic obstructive cardiomyopathy

Postoperative ventricular septal defect (post-op VSD) after septal myectomy in patients with hypertrophic obstructive cardiomyopathy is a rare and unexpected complication. We report a case of successful percutaneous closure of VSD following septal myectomy and mitral valve replacement in a patient with intrinsic mitral valve disease and severe mitral valve regurgitation together with hypertrophic obstructive cardiomyopathy.

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.