Transcatheter closure of congenital ventricular septal defect with Amplatzer septal occluders

Update on Transcatheter Interventions in Adults with Congenital Heart Disease

The field of adult congenital interventions is unique in the world of cardiac catheterization, combining the structural concepts commonly employed in pediatric heart disease and applying them to adult patients, who are more amenable to device intervention as they no longer experience somatic growth. Rapid advances in the field have been made to match the growing population of adult patients with congenital heart disease, which currently surpasses the number of pediatric patients born with congenital heart disease. Many congenital defects, which once required surgical intervention or reoperation, can now be addressed via the transcatheter approach, minimizing the morbidity and mortality often encountered within adult congenital surgeries. In this paper, we aim to provide a focused review of the more common procedures that are utilized for the treatment of adult congenital heart disease patients in the catheterization laboratory, as examples of current practices in the United States, as well as emerging concepts and devices awaiting approval in the future.

Arrhythmias in Patients with Congenital Heart Disease: An Ongoing Morbidity

With the aging of congenital heart disease (CHD) patients, the burden of arrhythmias is expanding. Atrial arrhythmias, especially intra-atrial reentrant tachycardia and atrial fibrillation, are the most prevalent forms of arrhythmia. Managing comorbidities, such as obesity, using pharmacotherapy, including antiarrhythmics and anticoagulants, and ablation therapy has become the cornerstone of arrhythmia management. Ventricular tachycardias are also not rare; however, except for tetralogy of Fallot patients, recommendations for the use of implantable cardioverter defibrillators for primary prevention in other CHD patients are still not well established. Patients with CHD might also present with atrioventricular blockages because of their anatomy or following a surgical procedure. The scope of this article is to review the current knowledge and discuss the future directions regarding arrhythmia management in CHD patients.

Update on Transcatheter Device Closure of Congenital Septal Defects

PURPOSE OF REVIEW

The goal of this paper is to review currently available devices for closure of atrial septal defects (ASDs) and ventricular septal defects (VSDs).

RECENT FINDINGS

Favorable results from the ASSURED trial resulted in FDA approval for the most recently developed device for transcatheter ASD closure in the United States. Further studies are required to assist in the development or approval of safe devices for transcatheter perimembranous VSD closure in pediatric patients. Device closure is the less invasive and preferred management option for many ASDs, with multiple studies demonstrating lower complication rates, shorter hospital stays, and lower mortality than surgical repair. Complex ASDs that make device closure more difficult include large defects, rim deficiencies, fenestrated defects, multiple defects, and the presence of pulmonary arterial hypertension. Device closure has also become an accepted alternative to surgery for some types of ventricular septal defects VSDs, though challenges and limitations remain. Future innovations including novel devices and techniques are needed to further expand on the types of defects that can be safely closed via transcatheter approach.

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.

Transesophageal echocardiography-guided percutaneous closure of multiple muscular ventricular septal defects with pulmonary hypertension using single device: A case report

BACKGROUND

Surgery is typically used to correct challenging ventricular septal defects (VSDs), such as VSD with pulmonary hypertension and multiple defects. In this case report, we would like to highlight the feasibility of multiple defects VSD closure with single device percutaneously using zero-fluoroscopy technique.

CASE PRESENTATION

A 7-year-old child was referred with the main symptom of shortness of breath. She started experiencing repeated respiratory tract infections, feeding issues, and failure to thrive at the age of six months. Her body weight was only 18 kg. TEE revealed several muscular VSD with 2-3 mm and 12 mm diameters, 3 mm spacing between VSD, L to R shunt, AR (-), and TR mild with septal leaflet tricuspid prolapse. Following right heart catheterization (Qp:Qs 3.5, PVRi 5.23WUmsq, PVR 4.55 WU, PVR/SVR 0.16), we made the decision to correct the defect using an Amplatzer Septal Occluder (AGA) No. 16 mm using transjugular method. Full device deployment was successfully performed with several episodes of PVC storm and severe bradycardia. One and a half years after the procedure, her TVG dropped to only 18 mmHg, her visible indicators of PH subsided, and the PA dilator treatment was discontinued. Her body weight had increased to 28 kg, and she had no complaints.

CONCLUSIONS

Our experience demonstrated that percutaneous closure of multiple VSD with a single device is possible, even with pulmonary hypertension.

Does transcatheter ventricular septal defect closure affect heart rate variability in children?

BACKGROUND

Heart rate variability (HRV) is a sign of the cardiac autonomic nervous system. Its evaluation in pediatric ventricular septal defect (VSD) cases before and after transcatheter closure contributes to an understanding of cardiac autonomic control.

METHODS

Nineteen children with VSDs treated with transcatheter closure and 18 healthy children were enrolled in this study. A 24-h Holter rhythm monitor was applied to all patients before VSD closure and to those in the control group. Holter rhythm monitoring was repeated at three months in the patient group. HRV parameters were measured using the Cardio Scan Premier 12® program. Frequency-domain (total power; very-low-frequency, low-frequency (LF), and high-frequency (HF) indices; and the LF/HF ratio) and time-domain (standard deviation of all RR intervals (SDNN), standard deviation of 5-min averages of RR intervals (SDANN), the SDNN index, percentage of the difference between adjacent RR intervals, and the square root of the mean of the sum of square differences between adjacent filtered RR intervals) parameters were assessed.

RESULTS

Before the procedure, SDNN, SDANN, and total power values were lower in the patient group than in the control group; other parameters were similar in the two groups. No significant difference in the SDNN, SDANN, or total power was detected between the patient and control groups in the third month, indicating that autonomic control of patients' hearts became normal during the third postoperative month. No correlation was detected between any hemodynamic parameters and any time-domain or frequency-domain parameters before closure.

CONCLUSION

This study showed that transcatheter closure of VSDs changed HRV parameters in pediatric patients.

Transcatheter Closure of Atrial and Ventricular Septal Defects: JACC Focus Seminar

The field of congenital interventional cardiology has experienced tremendous growth in recent years. Beginning with the development of early devices for transcatheter closure of septal defects in the 1970s and 1980s, such technologies have evolved to become a mainstay of treatment for many atrial septal defects (ASDs) and ventricular septal defects (VSDs). Percutaneous device closure is now the preferred approach for the majority of secundum ASDs. It is also a viable treatment option for selected VSDs, though limitations still exist. In this review, the authors describe the current state of transcatheter closure of ASDs and VSDs in children and adults, including patient selection, procedural approach, and outcomes. Potential areas for future evolution and innovation are also discussed.

The Clinical Outcomes of Ventricular Septal Rupture Secondary to Acute Myocardial Infarction: A Retrospective, Observational Trial

Background

Ventricular septal rupture (VSR) is a severe mechanical complication secondary to acute myocardial infarction (AMI) with a dreadful prognosis. The goal of our study was to evaluate the mortality and to identify the predictors of mortality for this population.

Methods

From June 2012 to July 2021, patients with VSR secondary to AMI were initially screened for eligibility in this study. The potential risk predictors were determined using appropriate logistic regression models.

Results

In this retrospective study, a total of 50 cases were included, and 14 patients survived and got discharged successfully. Univariable analyses indicated that the heart rate (HR), white blood cell (WBC) count, neutrophils count, serum glucose, serum creatinine, serum lactic acid, and the closure of rupture were significantly associated with mortality among these special populations.

Conclusion

This study found that such high mortality in patients with VSR after AMI was significantly correlated with these risk factors representing sympathetic excitation and large infarct size. Coronary revascularization combined with the closure of rupture might be helpful in improving their prognosis.

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.

Paroxysmal ventricular tachycardia as a rare complication of interventional closure of ventricular spetal defect and its treatment by radiofrequency catheter ablation: A case report (CARE-compliant)

INTRODUCTION

Trans-catheter closure of peri-membranous ventricular septal defects (VSDs) using Amplatzer-Type devices, has been widely reported in the past decade. We hereby report a rare complication of frequent premature ventricular contractions (PVCs) and paroxysmal ventricular tachycardia (PVT) sustained 48 days after the closure of VSD.More importantly, the arrhythmias were successfully treated with radiofrequency catheter ablation (RFCA) after medical therapy failed to restore and maintain sinus rhythm.

PATIENT CONCERNS

We reported an 8-year-old boy with frequent PVCs and PVT sustained 48 days after the closure of VSD. The boy has no palpitation, chest distress and other uncomfortable symptoms.

DIAGNOSIS

This patient was diagnosed as frequent PVCs and PVT by Holter monitoring for 24 hours.

INTERVENTIONS

RFCA was administered.

OUTCOMES

The patient was discharged 48 hours with no complication and remained asymptomatic 12 months after the ablation.

CONCLUSION

Radiofrequency ablation helps treat PVCs and PVT in children and has a higher efficacy in restoring and maintaining sinus rhythm.

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.

Transcatheter Device Closure of Perimembranous Ventricular Septal Defect in Pediatric Patients: Long-Term Outcomes

Aims

The aim of this study is to evaluate the safety and efficacy of transcatheter device closure of perimembranous ventricular septal defects in pediatric patients at long-term follow-up.

Materials and Methods

We prospectively studied 376 patients with perimembranous VSDs between September 2008 and December 2015 who underwent percutaneous closure at our center. Transthoracic echocardiography (TTE) and electrocardiogram were done before and after the procedure in all the patients. All patients were subjected to follow-up evaluation at 1, 3, 6, 12 months, and annually thereafter with TTE and electrocardiogram.

Results

A total of 376 patients (210 males and 166 females) underwent transcatheter closure of perimembranous VSD. Mean age of patients was 8.67 ± 3.02 (range 3-18 years) and mean weight was 21.15 ± 8.31 (range 8-65 kg). The procedure was carried out successfully in 98.93% of patients with no reported mortality. Rhythm disturbances occurred in 8.5% of patients after the procedure which included three cases of complete atrioventricular block.

Conclusion

This study shows that in experienced hands transcatheter closure of perimembrnous VSD is safe and effective at long-term follow-up. With minimal morbidity and no mortality, the transcatheter is an effective alternative to surgical closure in selected patients.

Assessment of left ventricular systolic function after VSD transcatheter device closure using speckle tracking echocardiography

BACKGROUND

This is a case-control study conducted on 30 children, 15 with VSD who performed VSD transcatheter device closure (group A) and 15 controls of matching age and gender (group B), in the period between September 2015 and February 2018. We aimed to assess the global left ventricular (LV) systolic function by 2D speckle tracking before and after ventricular septal defect (VSD) transcatheter closure, in comparison to normal controls. All patients were subjected to full history taking; general and cardiac examination; ECG; CXR; full transthoracic echocardiographic examination, including VSD number, size, and site; LV dimensions and volumes; estimated pulmonary artery pressure; right ventricular size and function; left ventricular circumferential; and radial strain imaging by 2D speckle tracking. Patients who had ventricular septal defect closed were reassessed by transthoracic echocardiography after 3 months.

RESULTS

The study included 15 children with VSD: 3 males and 12 females; their age ranged from 2 to 13 years; all had subaortic VSD except for 1 who had apical muscular VSD: VSD size ranged from 3 to 8 mm; PFM coil was used to close defect in all patients except for 2 patients who had an Amplatzer duct occlude I (ADOI) device, and 1 patient needed an additional vascular plug after significant hemolysis. Pre-procedurally, group A had a significantly higher LVEDD, LVESD, and LVEDV than group B. Mean circumferential strain was significantly higher (more negative) in group A than that in group B either pre- or post-procedure. Post-procedurally, there was a significant decrease in circumferential strain (less negative) and a significant increase in radial strain (more positive).

CONCLUSION

Following transcatheter VSD closure, there is a significant decrease in LV circumferential strain and a significant increase in LV radial strain, which conclude a decrease in LV volume overload with the improvement of its contractility.

Recent advances in managing septal defects: ventricular septal defects and atrioventricular septal defects

This review discusses the management of ventricular septal defects (VSDs) and atrioventricular septal defects (AVSDs). There are several types of VSDs: perimembranous, supracristal, atrioventricular septal, and muscular. The indications for closure are moderate to large VSDs with enlarged left atrium and left ventricle or elevated pulmonary artery pressure (or both) and a pulmonary-to-systemic flow ratio greater than 2:1. Surgical closure is recommended for large perimembranous VSDs, supracristal VSDs, and VSDs with aortic valve prolapse. Large muscular VSDs may be closed by percutaneous techniques. A large number of devices have been used in the past for VSD occlusion, but currently Amplatzer Muscular VSD Occluder is the only device approved by the US Food and Drug Administration for clinical use. A hybrid approach may be used for large muscular VSDs in small babies. Timely intervention to prevent pulmonary vascular obstructive disease (PVOD) is germane in the management of these babies. There are several types of AVSDs: partial, transitional, intermediate, and complete. Complete AVSDs are also classified as balanced and unbalanced. All intermediate and complete balanced AVSDs require surgical correction, and early repair is needed to prevent the onset of PVOD. Surgical correction with closure of atrial septal defect and VSD, along with repair and reconstruction of atrioventricular valves, is recommended. Palliative pulmonary artery banding may be considered in babies weighing less than 5 kg and those with significant co-morbidities. The management of unbalanced AVSDs is more complex, and staged single-ventricle palliation is the common management strategy. However, recent data suggest that achieving two-ventricle repair may be a better option in patients with suitable anatomy, particularly in patients in whom outcomes of single-ventricle palliation are less than optimal. The majority of treatment modes in the management of VSDs and AVSDs are safe and effective and prevent the development of PVOD and cardiac dysfunction.

Tricuspid stenosis: A rare and potential complication of ventricular septal occluder device

Asymmetrical septal occluder device (ASOD) has made percutaneous closure of ventricular septal defect an easy and effective management option. Although there are reports of aortic and tricuspid valvular regurgitation after deployment of ASOD, only few cases of tricuspid stenosis (TS) has been reported so far in the literature. We report a case of malaligned ASOD that occurred after successful device closure resulting in TS along with mild tricuspid and aortic regurgitation requiring surgical retrieval. Transesophageal echocardiography played crucial role in detecting the cause of tricuspid valve dysfunction besides providing continuous monitoring during the procedure. We intend to emphasize the need of echocardiographic evaluation of the tricuspid valvular apparatus and aortic valve during and after the device deployment even after the successful device closure to prevent this rare complication.

Anatomic and surgical factors affecting the switch from minimally invasive transthoracic occlusion to open surgery during ventricular septal defect repair

Background

This study aimed to investigate the specific causes for switching patients from minimally invasive transthoracic occlusion to surgical repair under cardiopulmonary bypass (CPB). By retrospectively analyzing 340 cases, we sought to provide the clinical reference for improving the success rate of minimally invasive transthoracic device closure of ventricular septal defect (VSD).

Methods

Among the 340 patients who underwent transthoracic closure of VSDs in the past 3 years at our hospital, 26 patients needed to be switched to surgical repair under CPB due to failure of transthoracic closure. We investigated the causes by retrospectively analyzing the findings from preoperative transthoracic echocardiography (TTE), intraoperative transesophageal echocardiography (TEE) and surgical exploration.

Results

Among the 340 patients who underwent transthoracic closure of VSDs, 26 patients (7.65%) were switched to surgical repair under CPB, which included 11 cases of membranous aneurysm (13.10%), 13 cases of perimembranous type (6.22%) and 2 cases of intracristal type (5.00%) according to their anatomic classifications. Among the 186 patients who underwent transthoracic closure during the first 17 months, 20 patients (10.75%) were switched to surgical repair under CPB. The main causes were failure of the delivery system to pass through the VSD in 7 patients, obvious residual shunts after releasing the occluder in 5 patients, significant shedding or shifting after releasing the occluder in 4 patients, significant regurgitation in adjacent valves in 3 patients and severe intraoperative complication (bleeding) in 1 patient. Among the 154 patients who underwent transthoracic closure during the late 17 months, 6 patients (3.90%) were switched to surgical repair under cardiopulmonary bypass. The main causes were significant residual shunts after releasing the occluder in 3 patients, significant regurgitation in adjacent valves in 2 patients after releasing the occluder and failure of the delivery system to pass through the VSD in 1 patient.

Conclusions

Among all the anatomic classifications, membranous aneurysm VSD had the highest risk for switching from minimally invasive transthoracic closure to surgical repair under CPB. During the early period, the surgeons were not yet skilled with the minimally invasive transthoracic closure procedure, and the main causes of switching to surgical repair under CPB were that the delivery system could not pass through the ventricular septal defect and significant residual shunts persisted after releasing the occluder. In contrast, in the late period, the surgeons were skilled with the minimally invasive transthoracic closure procedure, and the main causes were significant residual shunts and obvious regurgitation in adjacent valves after releasing the occluder.

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.

In-Hospital Outcomes and Long-Term Follow-Up after Percutaneous Transcatheter Closure of Postinfarction Ventricular Septal Defects

Postinfarction ventricular septal defects (VSD) represent a devastating complication of acute myocardial infarction and are associated with high mortality. Percutaneous interventional closure of postinfarction VSD has been proposed as a potential alternative to surgery. The study aimed to evaluate the therapeutic safety and efficacy of percutaneous interventional closure of postinfarction ventricular septal defects (VSD). Each patient was assigned to one of two groups, based on whether they died during hospitalization (death group) or survived (survival group) in this retrospective study. In-hospital and follow-up data were analyzed. Placement of the VSD occluder was successful in 12 procedures (80%). The mean defect size was 14.20 ± 4.89 mm. Compared to the patients who died, those who survived had higher systolic blood pressure, diastolic blood pressure, and left ventricular ejection fraction upon admission, as well as lower pulmonary/systemic flow ratio and shorter time from acute myocardial infarction to procedure. The incidence of cardiac shock and class IV heart failure was lower in the survival group than in the death group, and these factors correlated with in-hospital and 30-day mortality. Percutaneous closure of postinfarction VSD is an effective technique, which can be performed with a high procedural success rate.

Simultaneous transcatheter therapy for perimembranous ventricular septal defect combined with patent ductus arteriosus

OBJECTIVE

This study aims to assess the clinical efficiency and safety of simultaneous transcatheter interventional treatment for perimembranous ventricular septal defect (pmVSD) combined with patent ductus arteriosus (PDA).

METHODS

Twenty-five patients with pmVSD and PDA treated with simultaneous transcatheter interventions from April 2004 to December 2015 were included in this study. The mean age was 9.80 ± 8.14 years and the mean weight was 29.76 ± 14.82 Kg. Transthoracic echocardiography (TTE) and angiography were performed immediately after the procedure. Patients were re-examined by electrocardiogram, X-ray, and TTE at 2 days, 1 month, 3 months, and 6 months postoperatively.

RESULTS

The interventional procedure was successfully performed in all 25 patients. No intraoperative complication was noted. TTE examination of the VSD and PDA immediately after the procedure showed no residual shunt and the occluder was well positioned. Among these patients, four patients showed electrocardiogram changes after the procedure that resolved after drug therapy. The cardiothoracic ratio, left atrial diameter, left ventricular end-systolic diameter, and left ventricular end-diastolic diameter recovered to normal in most patients at 6 months postoperatively.

CONCLUSIONS

Simultaneously transcatheter interventional therapy is a safe and effective method for pmVSD combined with PDA.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effectiveness and Safety of Transcatheter Closure of Perimembranous Ventricular Septal Defects in Adults

This study was designed to determine the long-term safety and efficacy of using modified double-disk occluders for perimembranous ventricular septal defect (pmVSD) closure in adults. From January 2004 to December 2014, 337 adults with pmVSDs were treated through transcatheter intervention using 2 types of double-disk occluders; 302 patients received a symmetrical concentric pmVSD occluder, and 35 patients received an asymmetrical concentric pmVSD occluder. All patients were followed up through electrocardiography and transthoracic echocardiography until June 2015. The success rate was 100% for both procedures. During the median 71-month follow-up period, no cases of infective endocarditis, cerebrovascular accidents, heart failure, or death occurred. Two major adverse events (0.6%) were recorded: complete atrioventricular block requiring surgical treatment in one patient and severe tricuspid valvular regurgitation requiring surgical repair in another patient. Cardiac conduction block was the most common minor adverse event. The mean left ventricular (LV) end-diastolic volume decreased from 96.6 ± 23.2 ml before intervention to 86.0 ± 22.0 ml (p <0.05) at the 6-month follow-up visit. Previously enlarged LV chambers decreased to normal sizes during the follow-up period. In conclusion, transcatheter closure of pmVSDs using modified double-disk occluders was both safe and effective and yielded excellent long-term results in adults. The potential benefits of this intervention included remodeling of the heart, a reduced incidence of infective endocarditis and prevention of LV volume overload.

Conduction Disorders in Continuous Versus Interrupted Suturing Technique in Ventricular Septal Defect Surgical Repair

Background:

Ventricular septal defects (VSD) is one of the most frequent congenital cardiac malformations and cardiac conduction disorders are still one of the serious postoperative complications in this surgery.

Objectives:

This study aimed to compare the incidence of conduction disorders with the use of continuous compared to interrupted suturing techniques in VSD surgical repair.

Patients and Methods:

Previously recorded data of 231 patients who underwent surgical closure of VSD between January 2009 and January 2012 at the Rajaie cardiovascular medical and research center were retrospectively reviewed. VSD surgical repair was performed using continues suturing technique in group A patients (n = 163, 70.6%) and interrupted suturing technique in group B patients (n = 68, 29.4%).

Results:

The most common concomitant congenital anomaly was Tetralogy of Fallot (27.3%). Twenty-four (10.4%) patients had intraoperative cardiac arrhythmia, including 19 (8.2%) transient and 5 (2.2 %) permanent arrhythmia. During their ICU stay, ventricular arrhythmia and complete heart block were observed in 34 (14.7%) and 5 patients (2.2%), respectively. At the time of the last follow-up, incomplete right bundle branch block (RBBB), complete RBBB, RBBB with left anterior hemi-block, and complete heart block were identified in 84 (36.4%), 42 (18.2%), 29 (12.6%), and 5 patients (2.2%), respectively. The results revealed that group A patients were most likely to have had cardiac arrhythmias during their ICU stay and at the time of last follow-up (P < 0.001), while the intraoperative incidence of cardiac arrhythmia during surgery was not statistically significant between the two groups (P = 0.06).

Conclusions:

In the absence of any statistical differences in the other risk factors between the two groups, the difference in the incidence of conduction disorders can be attributed to the type of suturing used during the procedure.

Long-term Follow-up of "Simple" Lesions--Atrial Septal Defect, Ventricular Septal Defect, and Coarctation of the Aorta

Surgery for congenital heart disease has advanced significantly in the past 50 years, such that repair of "simple" lesions, such as atrial septal defect, ventricular septal defect, and coarctation of the aorta carries minimal risk, with mortality risk much less than 1%. It was once thought successful repair of these lesions was definitively corrective. There is mounting evidence, however, that there are long-term complications after these repairs, prompting the need for continued follow-up. This review describes the current understanding of diagnosis, treatment, and long-term outcomes for these patients, with the goal of advocating for lifelong surveillance. As the perioperative care of these repairs has evolved significantly over time, so must the way in which we study these patients in the long-term.

Echocardiographic Guided Closure of Perimembranous Ventricular Septal Defects

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous closure of ventricular septal defects

Isolated ventricular septal defect is the most common form of congenital heart disease. Surgery has been performed for many years and is considered the gold standard for the treatment of ventricular septal defects. However, it is associated with morbidity and mortality. Less invasive techniques have been developed and currently percutaneous closure of muscular and perimembranous ventricular septal defects has to be considered a possible alternative to the standard surgical approach.

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.

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

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

Percutaneous ventricular septal defect closure with Amplatzer devices resulting in severe tricuspid regurgitation

While percutaneous intervention is an alternative for patients who are not surgical candidates, the rate of morbidity and mortality is comparable to open repair. Appending the reported complications associated with percutaneous intervention (device mal-positioning, dislodgement, and entrapment in the sub-valvular apparatus), we report mechanical damage to the tricuspid valve (TV). Percutaneous closure with an Amplatzer septal occluder device was attempted on three patients who developed a ventricular septal defects (VSD) after myocardial infarction. In all three cases, damage to the tricuspid leaflet was noted post-procedure. The accompanying severe tricuspid regurgitation led to right ventricular failure, even in the patients where the VSD was considered successfully occluded. Despite successful deployment of the Amplatzer device, complications with catheter manipulation may still arise. Damage to the TV can occur during percutaneous VSD closure with Amplatzer device. Periprocedure TEE monitoring can detect damage to the tricuspid leaflets.

Outcomes of a modified approach to transcatheter closure of perimembranous ventricular septal defects

OBJECTIVES

To describe the immediate and midterm results of a modified method for transcatheter closure of perimembranous ventricular septal defects (pmVSDs).

BACKGROUND

Transcatheter closure of pmVSDs has been associated with development of heart block due to impingement on the ventricular conduction system. Ventricular septal aneurysms (VSAs) are common; the VSA tissue can serve as a target for the device without necessitating direct contact with the conduction system.

METHODS

Between 2004 and 2011, 15 patients underwent transcatheter closure of a pmVSD utilizing a device implanted into a VSA. Catheterization reports were examined in addition to pre-closure, post-closure, and current clinical, ECG, and echocardiographic data.

RESULTS

The median age was 20 years (4-61 years), and the most common indication for closure was increasing LV dilation. Four different Amplatzer devices were utilized. Following device implantation there was a decrease in Qp:Qs (1.7-1.1) and in RV:LV pressure ratio (0.36-0.31). There were no deaths, no device embolizations, and no new heart block or PR interval prolongation. Three patients developed a new right bundle branch block (RBBB). The median follow-up time was 1.5 years (4 months to 7.1 years). Two patients required further procedures for important residual shunting. Six continued to have a "trivial/small" residual leak, but only one had any degree (mild) of residual LV dilation. None of the complications were significantly associated with age or weight at the time of procedure, original size of the VSD, or size or type of the device used.

CONCLUSION

Transcatheter closure of pmVSD with placement of the device into the VSA is safe and effective, and may result in fewer instances of atrioventricular block and valve abnormalities than have been reported with alternative methods of pmVSD device closure. Persistent VSDs and new RBBBs remain an important issue.

Postimplant complications with transcatheter closure of congenital perimembranous ventricular septal defects: a single-center, longitudinal study from 2002 to 2011

BACKGROUND

Whether or not to close perimembranous VSDs (pmVSDs) by transcatheter techniques is controversial because of a high rate of complications as compared with surgical alternatives.

OBJECTIVE

We report the short- and long-term follow-up results of the use of several kinds of devices to close pmVSDs and the annual incidence of postimplant complications in our center.

METHODS

From June 2002 to June 2011, 232 patients with pmVSD underwent attempted transcatheter closure; closure was successful in 209 cases (90.1%). Six types of occlusive devices were used. Patient age, defect size, device type, device size and its relation to defect size, and transcatheter and fluoroscopy time were analyzed for correlation with annual incidence of postimplant complications.

RESULTS

There were no deaths during the follow-up period. Within 1 month after transcatheter closure, we found 91 adverse events (43.5%), but only 32 cases showed a trace amount of residual shunting. From 2002 to 2011, the annual incidence of postimplant complications gradually decreased, from 50% in 2002 to 17.6% in 2011. The use of Amplatzer occluder devices (r = 0.71, P = 0.033), double-disc symmetrical occluder devices (r = -0.68, P = 0.045), and transcatheter (r = 0.87, P = 0.003), and fluoroscopy time (r = 0.78, P = 0.02) were significantly correlated with the incidence of post-implant complications.

CONCLUSIONS

Results of transcatheter closure of pmVSD in terms of postimplant complications are encouraging in our center. It seemed that eccentric Amplatzer and domestic occluder may be at rather higher risk for postimplant complications. The incidence of postimplant complications may be minimized by skilled maneuvers, excluding rather small patients, and selecting the appropriate kind of occlusive device.

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

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transcatheter closure of congenital perimembranous ventricular septal defect in children using symmetric occluders: an 8-year multiinstitutional experience

BACKGROUND

Perimembranous ventricular septal defects (pmVSDs) are one of the most common forms of congenital cardiac malformation in children. Results of transcatheter pmVSD closure remain debatable, prompting the need for further evaluation with regard to the safety and efficacy of this procedure. The aim of the study was to analyze the safety, efficacy, and long-term follow-up data associated with transcatheter closure of pmVSDs in children using symmetric occluders.

METHODS

From December 2002 to October 2011, 525 children with pmVSDs between 2 and 12 years of age underwent transcatheter closure at three major heart centers in northwest China with symmetric pmVSD occluders. All patients were followed up until October 2011 with electrocardiogram and transthoracic echocardiography. Adverse events were recorded and evaluated.

RESULTS

There were 252 male and 273 female patients with an average weight of 21.5 kg. The mean age at the time of transcatheter closure was 5.6 years, and the average ratio of pulmonic to systemic blood flow was 2.5. Transcatheter intervention was successfully performed in 502 patients (95.6%). The median device size implanted was 6.5 mm (range, 4 to 18 mm). During a median 45-month follow-up period, no mortality occurred. A total of three major adverse events (0.6%) were reported; two were valve-related. Meanwhile, 104 minor adverse events were detected during the entire follow-up period. All individuals experiencing major adverse events were younger than 3 years of age. The incidence of major adverse events in patients younger than 3 years old was significantly higher than that of patients older than 3 years old (3.75% versus 0.00%; Fisher's exact test p=0.004).

CONCLUSIONS

Data from the current study suggest that transcatheter pmVSD closure using symmetric occluders displayed an excellent success rate and long-term follow-up results. The transcatheter approach provides a less-invasive alternative to open surgery and displays some promise in the treatment of pmVSDs in certain patient populations.

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

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

Intraoperative device closure of acquired left ventricular-right atrium shunt in a pediatric patient with pulmonary hypertension

A postoperative acquired left ventricular (LV) to right atrium (RA) shunt in a pediatric patient is a rare complication, which requires immediate intervention. We report a case of successful management of an acquired LV-RA shunt using an intraoperative closure device.

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

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