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

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.

Results of two different echocardiography-guided approaches to closure of perimembranous ventricular septal defects

OBJECTIVES

The feasibility of mini-invasive closure of perimembranous ventricular septal defects has been proven, but can cause surgical incision or sternum injury. A relevant but, to date, unanswered question is whether there exists a treatment without surgical trauma, radiation exposure and arterial complications.

METHODS

From May 2017 to January 2020, a total of 449 patients with perimembranous ventricular septal defect [mean age 5.0 ± 6.1 years (range 0.8-52.0 years)] were involved in this study and underwent 2 different echocardiography-guided operative procedures [percutaneous device closure (group A) or percardiac device closure (group B)] based on the patients' or their parents' choice. The clinical data were collected and a retrospective analysis was performed.

RESULTS

Fifty-five (96.5%) cases were successfully occluded in group A, and 2 (3.5%) patients were converted to percardiac device closure; 379 (96.7%) patients in group B underwent percardiac device closure, and 13 patients (3.3%) were turned to open-heart surgery after occlusion procedure failure. There were statistically significant differences (P < 0.05) between the 2 groups in operation time, postoperative hospitalization time and blood transfusion requirement. No acute complications or severe adverse events (death, valve injury, complete atrioventricular block and embolism) occurred either in the early period or during the follow-up.

CONCLUSIONS

Percutaneous device closure can achieve the same validity and safety as percardiac device closure for treating perimembranous ventricular septal defects with a more rapid recovery and less trauma.

Re-evaluation of the criteria for asymmetric amplatzer occluders in the closure of perimembranous ventricular septal defects: A case series report

RATIONALE

To discuss suitable criteria for the application of asymmetric Amplatzer occluders for perimembranous ventricular septal defects (pmVSDs).

PATIENTS CONCERNS AND DIAGNOSES

We retrospectively studied 18 children with perimembranous VSDs who underwent attempted asymmetric occluder closure between January 2015 and December 2018 in our center.

INTERVENTIONS

Asymmetric Amplatzer occluders were attempted to be placed to all the enrolled patients. We analyzed the diameter of the defects with the receiver operating characteristic curve (ROC) values, the size of the occluders attempted, the presence of aneurysm and the presence of aortic valve prolapse for each patient. Then, for patients who experienced successful device implantation, the therapeutic efficiency was evaluated by follow-up.

OUTCOMES

Only 5 out of a total of 18 patients completed successful device implantation. Compared with failed cases, successful cases demonstrated a significantly smaller VSD size (5.46 ± 1.03 mm vs. 8.73 ± 2.33 mm, P = 0.012) and had a low ratio of aortic valvar prolapse (20% vs. 76.92%, P = 0.026). Four out of 5 successful cases involved arrhythmia complications, but the rhythm of the heart recovered after drug treatment. According to the ROC and Youden analyses, the cut-off value of the defect size for successful asymmetric Amplatzer occluder implantation was no larger than 5.7 mm.

LESSONS

The application of an asymmetric Amplatzer occluder expands the range of indications for patients with superior localized VSD but is largely limited in cases with aortic valvar prolapse and large VSD sizes. All successful cases recovered from arrhythmia postprocedure.

Novel Strategy for Predicting Conduction Abnormalities During Transcatheter Closure of Perimembranous Ventricular Septal Defect in Adults

BACKGROUND

In this study we evaluated the feasibility and efficacy of predicting conduction system abnormalities under 3-dimensional (3D) electroanatomic mapping guidance during transcatheter closure of perimembranous ventricular septal defects (pmVSDs) in adults.

METHODS AND RESULTS

The distribution of the His-Purkinje system (HPS) close to the margins of pmVSDs in the left ventricle was identified using 3D electroanatomic mapping and near-field HPS was further confirmed by different pacing protocols. Of the 20 patients in the study, 17 (85%) were successfully treated by transcatheter intervention. The minimum distance between the margins of the pmVSD and near-field HPS, as measured by 3D electroanatomic mapping, ranged from 1.3 to 3.9 mm (mean [± SD] 2.5±0.7 mm). Five patients with a minimum distance <2 mm had a higher risk (3/5; 60%) for adverse arrhythmic events, whereas patients with a distance >2 mm were at a much lower risk (1/15; 6.7%) of procedure-related conduction block (P=0.032). No other adverse events were recorded during the follow-up period (median 30 months).

CONCLUSIONS

A minimum distance between the pmVSD and near-field HPS <2 mm was associated with a relatively high risk of closure-related conduction block. 3D electroanatomic mapping may be helpful in guiding decision making for transcatheter closure and reduce the incidence of adverse arrhythmic events.

Diagnosis and treatment of adults with congenital heart disease

Approximately 50 million adults worldwide have known congenital heart disease (CHD). Among the most common types of CHD defects in adults are atrial septal defects and ventricular septal defects followed by complex congenital heart lesions such as tetralogy of Fallot. Adults with CHDs are more likely to have hypertension, cerebral vascular disease, diabetes and chronic kidney disease than age-matched controls without CHD. Moreover, by the age of 50, adults with CHD are at a greater than 10% risk of experiencing cardiac dysrhythmias and approximately 4% experience sudden death. Consequently, adults with CHD require healthcare that is two- to four-times greater than adults without CHD. This paper discusses the diagnosis and treatment of adults with atrial septal defects, ventricular septal defects and tetralogy of Fallot.

Transcatheter perimembranous ventricular septal defect closure under transthoracic echocardiographic guidance without fluoroscopy

Background

Transcatheter device closure has become an alternative therapy for ventricular septal defect (VSD). This study aimed to investigate the feasibility and safety of transcatheter perimembranous VSD (pm-VSD) closure under transthoracic echocardiography (TTE) guidance alone.

Methods

Between October 2012 and July 2016, 118 patients with pm-VSD underwent an attempt of transcatheter device closure for pm-VSD through the femoral artery under TTE guidance alone. Patients were followed-up at 1, 3, 6, and 12 months after the procedure and yearly after discharge.

Results

The mean age was 11.7±12.5 years (range, 1.0-53.0 years) and the mean body weight was 32.2±21.6 kg (range, 11.5-102.0 kg). The mean diameter of the VSD was 4.0±1.1 mm (range, 3.0-8.0 mm). Transcatheter device closure under TTE guidance alone was successful in 111 patients. The average procedural time was 44.9±7.3 minutes (range, 29.0-65.0 minutes). All 111 patients were followed-up for 3.4±2.3 years. At the last follow-up, two patients had a residual shunt smaller than 2 mm, seven patients had right bundle branch block (RBBB) including one patient with complete RBBB, six patients had mild or less tricuspid regurgitation, and two patients still had trivial aortic regurgitation including one patient that had it before the procedure. Occluder malposition, complete atrioventricular block, or other complications were not observed.

Conclusions

Transcatheter pm-VSD closure can be successfully performed under TTE guidance alone with outcomes similar to those achieved with fluoroscopic guidance in selected patients with weight more than 10 kg and VSD smaller than 8 mm. However, long-term follow-up in a large number of patients would be necessary.

Echocardiography in Infective Endocarditis: State of the Art

PURPOSE OF REVIEW

In this review, we examine the central role of echocardiography in the diagnosis, prognosis, and management of infective endocarditis (IE).

RECENT FINDINGS

2D transthoracic echocardiography (TTE) and transesophageal echocardiography TEE have complementary roles and are unequivocally the mainstay of diagnostic imaging in IE. The advent of 3D and multiplanar imaging have greatly enhanced the ability of the imager to evaluate cardiac structure and function. Technologic advances in 3D imaging allow for the reconstruction of realistic anatomic images that in turn have positively impacted IE-related surgical planning and intervention. CT and metabolic imaging appear to be emerging as promising ancillary diagnostic tools that could be deployed in select scenarios to circumvent some of the limitations of echocardiography. Our review summarizes the indispensable and central role of various echocardiographic modalities in the management of infective endocarditis. The complementary role of 2D TTE and TEE are discussed and areas where 3D TEE offers incremental value highlighted. An algorithm summarizing a contemporary approach to the workup of endocarditis is provided and major societal guidelines for timing of surgery are reviewed.

Imaging of left-to-right shunt in adults

PURPOSE OF REVIEW

Left-to-right shunts are commonly seen in congenital heart diseases. This review aims to review the anatomy, physiology, and imaging of the four most common left-to-right lesions in adults.

RECENT FINDINGS

Reported late complications of left-to-right lesions provide guidance in follow-up imaging. Use of three-dimensional echocardiography helps not only in the diagnosis of these defects but also in assistance during device closure.

SUMMARY

Noninvasive imaging plays a significant role in the diagnosis and management of left-to-right lesions.

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

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