Transcatheter closure of acquired left ventricle to right atrium shunts

Successful Percutaneous Closure of Gerbode Defect and Right Atrial-Aortic Fistula Following Infective Endocarditis

We report a case of infective endocarditis with a septal abscess that was complicated with abnormal blood flow from the left ventricle to the right atrium (Gerbode defect) along with abnormal blood flow from the aorta to the right atrium (atrial-aortic fistula). This is the first reported case of successful correction of both defects by a percutaneous approach.

Percutaneous Closure of an Iatrogenic Intracardiac Shunt in Treating Torrential Tricuspid Regurgitation

A patient presented with severe right heart failure due to a large LV-to-RA shunt with left-to-right shunting and torrential tricuspid regurgitation 6-weeks following surgical sub-aortic stenosis resection. Retrograde delivery of an Occlutech ventricular septal defect device produced instantaneous resolution of shunt, reduction in tricuspid regurgitation, and impressive diuresis of 28 kg.

Three centers experience with device closure of congenital Gerbode-type perimembranous ventricular septal defects

OBJECTIVES

We aim to evaluate our experience with interventional closure of Gerbode-type perimembranous ventricular septal defects (pmVSDs).

METHODS

We performed three-center retrospective data review of patients with congenital indirect Gerbode-type pmVSDs treated percutaneously between August 2017 and May 2021. Standard safety and latest follow-up outcomes were assessed.

RESULTS

Ten patients (six females) were identified with a median age of 6.8 years (range: 2.5-54) and a median weight of 26.5 kg (range: 12-88). The median left ventricular defect size was 10 mm (range: 3-15.5). On baseline ultrasound, 6 patients had absent subaortic rim , 6 patients had trivial aortic regurgitation, and 3 patients had tear-drop-type (small) aortic cusp prolapse. The tricuspid regurgitation was graded II (n = 5) and III (n = 5). Five Lifetech Konar-Multifunctional occluders, four Amplatzer duct occluders II and one Amplatzer duct occluder I were implanted. The median fluoroscopy time was 10.4 min (range: 4.3-20.2). Pre-existing aortic regurgitations remained identical. One new aortic regurgitation was identified before discharge and remained trivial after 48 months of follow-up. No heart block or tricuspid stenosis was observed on a median follow-up of 17 months (range: 3-48). All patients are symptom-free with complete shunt closure and significant regression or resolution of tricuspid regurgitation.

CONCLUSIONS

Despite anatomical challenges, interventional closure of congenital indirect Gerbode-type pmVSD appears to be feasible, safe, and most importantly clinically effective using different commercially available devices. Amplatzer duct occluder II and Lifetech Konar-Multifunctional occluder offer interesting specifications to retrogradely target this specific defect with success.

The Gore Cardioform Atrial Septal Defect Occluder: A novel solution to the management of severe hemolysis following transcatheter septal defect closure

Significant hemolysis is a recognized complication of transcatheter high-velocity shunt occlusion using some Amplatzer devices. We describe a case of severe hemolysis following occlusion of an iatrogenic Gerbode defect with an Amplatzer muscular ventricular septal defect occluder successfully managed by transcatheter device removal and reocclusion with a Gore Cardioform Atrial Septal Defect Occluder.

Transcatheter device closure of perimembranous ventricular septal defect associated with indirect Gerbode defect: A retrospective study

Perimembranous ventricular septal defect (pmVSD) is a common congenital heart disease that is sometimes associated with indirect left ventricle (LV) to right atrium (RA) shunt (indirect Gerbode defect). This defect has a rare chance of spontaneous closure and therefore was usually closed surgically in the past, but more recently transcatheter closure has been reported by a few authors. In our study, we have described a series of 14 children (age ranging from 1.2 to 12 years and weight ranging from 7.2 to 25.5 kg) with the above-mentioned defect which were closed by various interventional devices. The procedures were successful in complete elimination of pmVSD and immediate reduction of indirect LV-RA shunts with negligible residual tricuspid regurgitation on follow-up. In our midterm experience, the judicious use of double-disc devices is efficacious for occluding pmVSD associated with indirect Gerbode defect.

Gerbode defect following surgical mitral valve replacement and tricuspid valve repair: a case report

Background

Gerbode defect is a congenital or acquired communication between the left ventricle and right atrium. While the defect is becoming a more well-recognized complication of cardiac surgery, it presents a diagnostic and therapeutic challenge for providers. This case highlights the predisposing factors and imaging features that may assist in the diagnosis of Gerbode defect, as well as potential approaches to treatment.

Case summary

We report a patient with severe mitral stenosis as a result of remote mediastinal radiation who underwent extensive decalcification during surgical mitral valve replacement and tricuspid valve repair. Following the procedure, he developed progressive heart failure refractory to medical management. Extensive workup ultimately led to the diagnosis of iatrogenic acquired Gerbode defect. Close collaboration between adult cardiology, cardiothoracic surgery, and the congenital cardiology services led to an optimal treatment plan involving percutaneous closure of the defect.

Discussion

Gerbode defect is a rare complication of invasive procedures involving the interventricular septum or its nearby structures. An understanding of the key echocardiographic features will aid providers in timely diagnosis. Percutaneous repair should be strongly considered for patients who may be poor surgical candidates.

Ruptured Sinus of Valsalva Aneurysm and Gerbode Defects: Patient and Procedural Selection: the Key to Optimising Outcomes

PURPOSE OF REVIEW

In this review, we reflect on the historical background, clinical features and imaging techniques used to assess Gerbode defects and sinus of Valsalva aneurysms. We aim to review the evolution of treatment strategies and the progression towards less invasive management for these conditions.

RECENT FINDINGS

While transthoracic echocardiography is often diagnostic, transesophageal echocardiography (2D and 3D) has improved our understanding of these defects and allowed us to more accurately define their anatomy. Cardiac MRI provides improved assessment of the physiological impact of defects by quantifying shunt volume. Transcatheter techniques are currently vying with surgery as the mainstay of treatment. New insights are being discovered regarding diagnostic modalities and treatment pathways. Defining criteria for patient selection for catheter or surgical therapy is essential when deciding on the optimum intervention for the individual patient.

Percutaneous Closure of 2 Paravalvular Leaks and a Gerbode Defect after Mitral Valve Replacement for Infective Endocarditis

Surgical valve replacement after infective endocarditis can result in local destructive paravalvular lesions. A 30-year-old woman with infective endocarditis underwent mitral valve replacement that was complicated postoperatively by 2 paravalvular leaks. During percutaneous closure of the leaks, a Gerbode defect was also found and closed. We discuss our patient's case and its relation to others in the relevant medical literature. To our knowledge, we are the first to describe the use of a percutaneous approach to close concomitant paravalvular leaks and a Gerbode defect.

Transcatheter closure of left ventricle to right atrial communication using cera duct occluder

Left ventricle—right atrial communication could be congenital (Gerbode defect) or acquired as a complication of surgery or infective endocarditis and leads to volume overloading of pulmonary circulation. Two types, direct and indirect types are known depending on the involvement of septal tricuspid leaflet. Transcatheter closure of this defect is feasible and appears an attractive alternative to surgical management. Various devices like Amplatzer duct occluder I, II, Muscular ventricular septal defect device etc. have been used to close this defect. We report two patients, a preteen boy with direct left ventricle-right atrial communication as post operative complication and an adult female with indirect communication who underwent transcatheter closure with Cera duct occluder (Lifetech Scientific (Shenzhen), China).

Simultaneous "traumatic Gerbode" and aortic rupture due to blunt chest trauma

The Gerbode defect is characterized by a perimembranous ventricular septal defect between the left ventricle and the right atrium. This intracardiac shunt is a congenital defect but may be iatrogenic after valve surgery or atrioventricular node ablation, may be the result of endocarditis or may be traumatic. It is really rarely encountered as sequelae of non-penetrating heart trauma, and their clinical manifestations may often be unrecognized in the multi-injured patient. However, they are serious complications, and their diagnostic approach is not always feasible. We hereby present a case of a young man with the left ventricle to the right atrium communication after blunt thoracic trauma due to a car accident and concomitant rupture of the thoracic aorta. We present also the case and the ways of treatment according to the international bibliography.

Single-Stage Repair of an Unusual Association: Congenital Gerbode Defect, Hypoplastic Aortic Arch, and Partially Anomalous Pulmonary Venous Return in an Infant

We present the case of a two-month-old male with congenital Gerbode defect, hypoplastic aortic arch, and left-sided partially anomalous pulmonary venous return. The patient underwent single-stage surgical repair, which consisted of aortic arch advancement with resection of the coarctation segment, pulmonary vein repair, and primary closure of the Gerbode defect. The anomalous pulmonary vein posed a particular challenge due to its size and distance from the left atrium, which we approached with a posterior atrial wall trapdoor baffle technique, without mobilizing the affected vein. Postoperatively and at one year follow-up, there was no evidence of residual lesions and there was unobstructed flow pattern across the aortic arch and the affected pulmonary vein.

Amplatzer duct occluder II for closure of congenital Gerbode defects

BACKGROUND

Congenital left ventricle to right atrial communications (Gerbode defects) are extremely rare (0.08%) type of ventricular septal defects. They were traditionally closed by surgery in the past. There are few case reports and small series of acquired and congenital Gerbode defects, closed with various types of devices. Aim of our study is to assess the feasibility, efficacy, and complications of transcatheter closure of congenital Gerbode defects with Amplatzer duct occluder II (ADO II).

MATERIAL

Twelve consecutive cases of Gerbode defects, age ranging from 10 months to 16 years (mean 6.7 years), weight ranging from 6.5 kg to 34 kg (mean 19.3 kg), were diagnosed on transthoracic echocardiography.

RESULTS

Transcatheter closure of Gerbode defects was done successfully through retrograde approach with ADO II. No aortic or tricuspid regurgitation or residual shunt occurred in any of the patients. One patient developed transient complete heart block needing temporary pacing.

DISCUSSION

The soft low profile, easily trackable ADO II appears to be ideal for closure of Gerbode defects, as the central cylinder fits in the defect and the soft retention discs on either side, without polyester material, do not impinge on either aortic, mitral, or tricuspid valve. We report the successful transcatheter closure of twelve cases of congenital Gerbode defects with ADO II.

CONCLUSIONS

Transcatheter closure of congenital Gerbode defects with ADO II is safe, effective, and an attractive alternative to surgical closure. ADO II appears to be tailor made for Gerbode defects, as the success rate is very high and complication rate is very low.

Acquired left ventricle-to-right atrium shunt: clinical implications and diagnostic dilemmas

BACKGROUND

The acquired left ventricle-to-right atrium (LV-RA) shunt (Gerbode defect) is rare but it can sometimes be a critical condition. The diagnosis is quite challenging largely due to its exotic anatomic features and diagnostic difficulties. This study aims to present the clinical features and diagnostic solutions of this rare lesion.

METHODS

Data source was based on a comprehensive literature retrieval of acquired LV-RA shunts of 1990-2014.

RESULTS

Most of the acquired LV-RA shunts are of either a postoperative or an infective etiology. Transthoracic echocardiography showed a 62.2% accurate diagnosis, 13.4% inclusive diagnosis, 9.8% missed diagnosis, and 14.5% misdiagnosis rate. The accurate diagnostic rate of transthoracic echocardiography was significantly lower than that of the transesophageal echocardiography or cardiac catheterization. The LV-RA shunts are often misinterpreted as mitral regurgitation, pulmonary hypertension, tricuspid regurgitation, Valsalva aneurysm rupture, and subaortic/high perimembrane/residual ventricular septal defect. Surgical, interventional, and conservative treatments were applied in 57.8, 24.4, and 17.8% patients, respectively. Prognosis showed an event-free survival of 85%, a comorbidity of 9.1%, and a mortality of 13.6%.

CONCLUSIONS

A high jet detected in the right atrium with uncertain origin and course has to appeal to additional diagnostic techniques including transesophageal echocardiography, cardiac catheterization, or cardiac magnetic resonance imaging for differential diagnoses. Small restrictive shunts are preferred with conservative treatments, high-risk patients are candidates of interventional therapy, and the patients with unstable hemodynamics warrant an open heart surgery. Careful operative maneuver, good control of intracardiac infection, preservation of heart function, etc., are mandatory for the prevention of the development of an acquired LV-RA shunt.

Transcatheter occlusion of a left ventricular to right atrial communication by an Occlutech duct occluder

Left ventricular to right atrial communication is a rare congenital or acquired heart defect. There are many reports of successful transcatheter closure of this defect. We describe the device closure of one such communication in a 5-year-old girl using the Occlutech duct occluder. We believe that this device may have some advantages over the devices previously used for this purpose.

Left ventricular to right atrial shunt (Gerbode defect): congenital versus acquired

Introduction

Congenital left ventricular to right atrial (LV-RA) shunt (Gerbode defect) is rare, while acquired LV-RA shunt has been increasingly reported. As yet, systematically incorporated data of the LV-RA shunt have not been presented.

Aim

To present the clinical features, diagnostic challenge and management strategies of congenital and acquired LV-RA shunts.

Material and methods

The data source was based on a comprehensive literature retrieval of the LV-RA shunt in the period 1990–2013.

Results

In comparison with the acquired Gerbode defect, the congenital Gerbode defect group of patients were younger and were associated more often with additional congenital disorders. Previous cardiac surgery and infective endocarditis were the two major aetiologies of the occurrence of the acquired shunts. Paravalvular abscess was associated in 10.2% and atrioventricular block in 13.6% of the acquired group patients. Transoesophageal echocardiography showed a higher diagnostic accuracy, lower missed diagnosis and lower inclusive diagnosis rates, in comparison to transthoracic echocardiography, but the misdiagnosis rates of the two modalities did not differ from each other. Four (4.5%) of the acquired group patients were complicated by atrioventricular block following surgical or interventional closure of the shunt. Eight (9.1%) patients died in the acquired group, but no patient died in the congenital group.

Conclusions

The diagnosis of an LV-RA shunt is quite challenging, especially in the context of coexisting abnormalities including an additional intracardiac shunt, tricuspid regurgitation, pulmonary artery hypertension and infective endocarditis, which have to be carefully differentiated from the shunt by further investigations. A better control of infective complications and careful manoeuvres during surgery may help to keep the LV-RA-sensitive septum intact.