Treatment of isolated ventricular septal defects in children: Amplatzer versus surgical closure

Key Regulatory Differentially Expressed Genes in the Blood of Atrial Septal Defect Children Treated With Occlusion Devices

Atrial septal defects (ASDs) are the most common types of cardiac septal defects in congenital heart defects. In addition to traditional therapy, interventional closure has become the main treatment method. However, the molecular events and mechanisms underlying the repair progress by occlusion device remain unknown. In this study, we aimed to characterize differentially expressed genes (DEGs) in the blood of patients treated with occlusion devices (metal or poly-L-lactic acid devices) using RNA-sequencing, and further validated them by qRT-PCR analysis to finally determine the expression of key mediating genes after closure of ASD treatment. The result showed that total 1,045 genes and 1,523 genes were expressed differently with significance in metal and poly-L-lactic acid devices treatment, respectively. The 115 overlap genes from the different sub-analyses are illustrated. The similarities and differences in gene expression reflect that the body response process involved after interventional therapy for ASDs has both different parts that do not overlap and the same part that crosses. The same portion of body response regulatory genes are key regulatory genes expressed in the blood of patients with ASDs treated with closure devices. The gene ontology enrichment analysis showed that biological processes affected in metal device therapy are immune response with CXCR4 genes and poly-L-lactic acid device treatment, and the key pathways are nuclear-transcribed mRNA catabolic process and proteins targeting endoplasmic reticulum process with ribosomal proteins (such as RPS26). We confirmed that CXCR4, TOB1, and DDIT4 gene expression are significantly downregulated toward the pre-therapy level after the post-treatment in both therapy groups by qRT-PCR. Our study suggests that the potential role of CXCR4, DDIT4, and TOB1 may be key regulatory genes in the process of endothelialization in the repair progress of ASDs, providing molecular insights into this progress for future studies.

Spanish registry of percutaneous VSD closure with NitOcclud Lê VSD Coil device: lessons learned after more than a hundred implants

INTRODUCTION AND OBJECTIVES

The NitOcclud Lê VSD Coil was specifically designed for transcatheter occlusion of ventricular septal defects (VSD) and became available for this purpose in August 2010. Our objective was to describe the Spanish experience of this technique and analyze its reliability and short- to mid-term efficacy.

METHODS

National multicenter observational study, which retrospectively recruited all patients (of any age) with VSD (of any location or type) who underwent percutaneous NitOcclud occlusion, using an intention-to-treat analysis, until January 2019.

RESULTS

A total of 117 attempts were made to implant at least 1 NitOcclud in 116 patients in 13 institutions. The median [range] age and weight was 8.6 [0.4-69] years and 27 [5.8-97] kg, respectively. In 99 patients (85%), the VSD was an isolated congenital defect. The location was perimembranous in 95 (81%), and 74 (63%) of them were aneurysmatic. The mean fluoroscopy time was 34 [11.4-124] minutes. Of the 117 attempts, 104 were successful (89%) with a follow-up of 31.4 [0.6-59] months. At the last review, final complete occlusion of the defect without residual shunt or with only a minimal shunt was achieved in 92.3% (no shunt, n=73; trivial shunt, n=23). Four patients required a second procedure for residual shunt occlusion. Two devices had to be surgically explanted due to severe hemolysis. There were no deaths or other major complications.

CONCLUSIONS

The NitOcclud device can be used successfully for a wide anatomical spectrum of VSD. The main issue is residual shunt, but its incidence decreases over time. The incidence of hemolysis was very low and no permanent changes were detected in atrioventricular conduction.

Comparison of complications between transcatheter and surgical ventricle septal defect closure: a single-center cohort study

BACKGROUND Some ventricular septal defects (VSDs) require an interventional procedure for closure. Transcatheter and surgical closures of VSD have similar effectiveness, but transcatheter VSD closure is considered associated with less complication than surgical closure. This study aimed to compare mid-term or long-term complications of transcatheter and surgical VSD closures. METHODS This was a retrospective cohort study compared the complication rates of transcatheter and surgical VSD closures performed in Cipto Mangunkusumo Hospital from January 1, 2010, to April 30, 2017, with 34 subjects in each group. The inclusion criteria were as follows: single lesion outlet perimembranous or doubly committed subarterial VSD, age 2–18 years, body weight >8 kg, and no arrhythmia. Electrocardiography and echocardiography were done to collect primary data. Other data were collected from medical records. Mid-term complications occurred 1–24 months after interventional closure. Long-term complications occurred 24 months after interventional closure. Complications were arrhythmia, valve regurgitation, and residual shunt. Data were analyzed by chi-square test. RESULTS The rate of worsening valve regurgitation was higher in the transcatheter group than in the surgical group (16 versus 11, p = 0.322). The number of patients with residual shunts were similar between the transcatheter group and surgical group (5 versus 5; p = 1.000). Both complications were found in mid- and long-term. Arrhythmia as a long-term complication occurred in five and seven patients in the transcatheter and surgical groups, respectively (p = 0.752). CONCLUSIONS Transcatheter and surgical VSD closures have similar mid or long-term complications.

The Destiny of Postoperative Residual Ventricular Septal Defects After Surgical Repair in Infants and Children

PURPOSE

Residual ventricular septal defects (rVSDs) of small size are commonly seen on transesophageal echocardiography after surgical repair. This study aimed to determine the destiny of rVSD found on intraoperative echocardiogram.

METHODS

Patients undergoing surgical repair of VSD as the primary procedure with available intraoperative and discharge echocardiograms between 2007 and 2017 were reviewed. Presence of an rVSD on intraoperative echo triggered review of discharge echo and of subsequent follow-up echocardiograms.

RESULTS

One hundred four patients were analyzed. The mean age and weight for the entire cohort were 1.4 ± 2.9 years (median, 5.4 months; range, 29 days to 14 years) and 8.8 ± 9.9 kg (median, 5.1 kg; range, 2.7-58 kg), respectively. Sixty (57%) patients had rVSD at discharge, with mean size of residual VSD of 1.38 ± 0.92 mm (mode, 0.6; median, 2.2 mm; range, 0.5-3.9 mm). The mean follow-up time was 3.7 ± 3.1 years (range, 1 month to 9.3 years). Among those with rVSD at discharge, a residual shunt persisted in 73% at one-month follow-up. On follow-up at three years postdischarge, of the 60 patients with early rVSD, 6 had a persistent rVSD (10%) with a mean diameter of 3.0 ± 0.8 mm (range, 2.4-3.9 mm).

CONCLUSIONS

Residual VSD after surgical repair is detected frequently on postoperative echocardiogram. The presence of rVSD was not associated with any preoperative, intraoperative, or postoperative factors. By three years of follow-up, only six patients continued to demonstrate rVSD with a mean diameter of 3 mm, suggesting that defects 3 mm or greater may be less likely to close spontaneously after three years.

Comparisons of perventricular device closure, conventional surgical repair, and transcatheter device closure in patients with perimembranous ventricular septal defects: a network meta-analysis

Background

Treatments for perimembranous ventricular septal defects (pmVSD) mainly include conventional surgical repair (CSR), transcatheter device closure (TDC), and perventricular device closure (PDC). We aimed to perform a network meta-analysis to compare the three approaches in patients with pmVSD.

Methods

We searched for comparative studies on device closure and conventional repair for pmVSD to April 2020. A network meta-analysis was performed under the frequentist frame with risk ratio and 95% confidence interval. The main outcome was the procedural success rate. Additional outcomes were postoperative complications, including residual shunt, intra-cardiac conduction block, valvular insufficiency, incision infection, and pericardial effusion.

Results

Twenty-four studies of 8113 patients were included in the comparisons. The pooled estimates of success rate favored the CSR compared with the PDC. No significant differences of success rate were found in the TDC versus CSR and the PDC versus TDC. The pooled estimates of incidences of the residual shunt, new tricuspid regurgitation, incision infection, and pericardial effusion favored the PDC compared with the CSR. There were no significant differences between the PDC and TDC approaches in all outcomes except new aortic regurgitation.

Conclusion

The PDC technique not only reduces the risk of significant complications compared with the CSR, but also produces not inferior results compared with the TDC in selected pmVSD patients.

PROSPERO registration number

CRD42019125257.

Comparison of transcatheter versus surgical closure of perimembranous ventricular septal defect in pediatric patients: A systematic review and meta-analysis

OBJECTIVE

Perimembranous ventricular septal defect (pmVSD) is a common congenital heart disease (CHD) usually treated with either catheter or surgical closure. Superiority of one procedure over the other in children is still a matter of debate. We performed this meta-analysis to compare the clinical outcomes and cost of transcatheter and surgical closure of pmVSD in children.

MATERIALS AND METHODS

We searched seven databases (MEDLINE, PubMed, EMBASE, Google Scholar, CENTRAL, CINHAL, and Cochrane library) and literature references for articles published in the past 10 years (between January 2008 and January 2018) comparing closure of pmVSD by both procedures in children. The outcomes of interest were success rate, residual shunt, need for blood transfusion, complications especially complete atrioventricular block, length of hospital stay, and cost.

RESULTS

A total of 1750 articles were identified. However, only five studies fulfilled the inclusion criteria. As regards success rate, no significant difference was found between surgical and catheter closure. Residual shunt was significantly lower in catheter closure than surgical closure [risk ratio (RR) = 0.44; 95% confidence interval (CI), 0.23-0.83, p = 0.01). The need for blood transfusion and the length of hospital stay were significantly lower in the catheter closure compared to surgical closure (RR = 0.02; 95% CI, 0.01-0.08; p < 0.00001), (RR = -4.81; 95% CI, -7.76 to -1.86; p = 0.001), respectively. However, overall complications, complete atrioventricular block, and the cost were comparable in both procedures.

CONCLUSION

Transcatheter closure of pmVSD in children was as effective as surgical closure with a lower residual shunt and need for blood transfusion, and shorter hospital stay.

The History of Surgery at the Montreal Heart Institute

The Montreal Heart Institute (MHI) is a specialty hospital dedicated to cardiology and heart surgery. Founded in 1954 by Paul David, it is currently affiliated with the Université de Montréal. The Montreal Heart Institute is a center that has rested on the shoulders of multiple pioneers over the past 63 years. Renowned for its sustained excellence and commitment to patient care, the MHI also focuses on research and innovation. It has become one of the leading heart institutions in modern cardiac surgery and also one of the busiest cardiac surgery centers in the country. Our leaders have impacted the treatment of patients with heart diseases through clinical care and education. Staff surgeons have been trained at top centers across the world for the benefit of Canadian patients. The MHI was a pioneer in heart transplantation and CABG surgery and focuses on evaluative research of new technology.

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.

Comparison of percutaneous device closure versus surgical closure of peri-membranous ventricular septal defects: A systematic review and meta-analysis

BACKGROUND

While percutaneous device closure (PDC) is a first-line therapy for isolated muscular ventricular septal defects (mVSD), surgery is still the preferred approach for peri-membranous ventricular septal defects (pmVSD).

OBJECTIVE

We sought to compare the outcomes of percutaneous versus open surgical closure of pmVSDs.

METHODS

PubMed, Cochrane Library, and Web of Science databases were searched through October 15, 2014 for English language studies comparing outcomes of PDC with surgical closure of pmVSDs. Study quality, publication bias, and heterogeneity were assessed. A meta-analysis of selected studies was performed using a random effects model. Comparison was done for early (<1 month) safety and efficacy outcomes.

RESULTS

Seven studies with a total of 3,134 patients (PDC = 1,312, surgery = 1,822) were identified. Patients in the PDC group were older than those treated surgically (mean age 12.2 vs. 5.5 years, respectively). In six out of seven studies, the mean VSD size was found to be comparable between the treatment arms (PDC 4.9 mm vs. surgery 6.0 mm). Males represented 52% of patients in either group. Follow-up ranged from 5 to 42 months. No significant differences were observed between PDC vs. surgery in terms of procedural success rate [relative risk (RR): 1.00, confidence interval (CI): 0.99-1.00; P = 0.67]. Combined safety end points for major complications (early death/reoperation/permanent pacemaker) were similar in both groups (RR: 0.55, CI: 0.23-1.35; P = 0.19) as were as other outcomes like post-procedure significant residual shunt (RR: 0.69, CI: 0.29-1.68; P = 0.41), significant valvular (aortic/tricuspid) regurgitation (RR: 0.70, CI: 0.26-1.86; P = 0.47), and advanced heart block (RR: 0.99, CI: 0.46-2.14; P = 0.98). The need for blood transfusion (RR: 0.02, CI: 0.00-0.05; P < 0.001) and duration of hospital stay [standard mean difference (SMD) -2.17 days, CI: -3.12 to -1.23; P < 0.001] were significantly reduced in the PDC group.

CONCLUSION

Percutaneous closure of pmVSD when performed in a selected subgroup of patients is associated with similar procedural success rate without increased risk of significant valvular regurgitation or heart block when compared with surgical closure.

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.

Severe aortic valve regurgitation after percutaneous ventricular septal defect closure

Percutaneous closure of ventricular septal defect is now commonly used. We report a rare case, and especially a rare image of aortic leaflet damage caused by percutaneous ventricular septal device.

Transcatheter closure of the perimembranous ventricular septal defect-preclinical trial of a new Amplatzer device

OBJECTIVES

This study assessed the feasibility and efficacy of implanting a new nitinol device for closure of perimembranous ventricular septal defects in a swine model.

BACKGROUND

Perimembranous ventricular septal defect occurs in 80% of patients requiring treatment for congenital heart disease.

METHODS

The Amplatzer perimembranous ventricular septal occluder device (pmVSO2 device, AGA Medical Company, Plymouth MN) is a new transcatheter Nitinol device containing polyester fabric designed to close the perimembranous ventricular septal defect (VSD). The device has 75% reduction in radial force, 45% reduction in clamping force, and increased stability as compared to the previous version. The device was implanted in six swine with naturally occurring perimembranous VSD with immediate, 1, 7, ∼30, and ∼90 day followup by echocardiography, angiography, and final pathological examination.

RESULTS

The device was successfully implanted in all animals and was retrievable and repositionable. There was complete occlusion of the VSD in five of six cases without embolization. There was no thrombus formation on the device or occurrence of complete heart block. A single instance of a tiny residual shunt was attributed to capture of tricuspid valve apparatus.

CONCLUSIONS

The success of this animal study confirms safety and feasibility of the Amplatzer pmVSO2 device. Human trials are planned.

Arrhythmias after transcatheter closure of perimembranous ventricular septal defects with a modified double-disk occluder: early and long-term results

With the development of interventional techniques and devices, transcatheter closure of perimembranous ventricular septal defect has been widely performed. However, there has been a lack of long-term follow-up results about postoperative ECG changes of PmVSD patients. We report our experience of early and late arrhythmias after transcatheter closure of PmVSD with a modified double-disk occluder (MDVO). We performed a retrospective review of 79 patients (47 males, 32 females) between September 2002 and May 2007 who underwent transcatheter closure of perimembranous ventricular septal defect. Symmetric and asymmetric PmVSD occluders were used. The diameter of the evaluated defects ranged from 3 to 12 mm, as measured by TTE and 3 to 15 mm by left ventriculography. Most cases of PmVSD were treated successfully with a single procedure, resulting in a successful closure rate of 97% (77/79 patients). There was no death in any of the patients. After the operation, 79 patients were followed-up for a range of 10-76 months (35.3 ± 17.4 months). In this series, 11 cases of incomplete right bundle branch block and five cases of complete right bundle branch block occurred during the early period after operation. During long-term follow-up, these issues declined in prevalence to five and four cases, respectively. Moreover, reversible third-degree AVB occurred during closure or after the procedure, and two of the three patients with reversible AVB received a temporary heart pacemaker implantation. These patients recovered 1 h, 6 days, and 9 days later, respectively. During 10-76 months of follow-up, no complications occurred in any of the patients, including residual shunt, severe aortic valve, or tricuspid valve regurgitation. Device closure of perimembranous ventricular septal defects with a modified double-disk occluder (MDVO) resulted in excellent closure rates and acceptably low arrhythmia rates.