Percutaneous Device Occlusion and Minimally Invasive Surgical Repair for Perimembranous Ventricular Septal Defect

Transfemoral Occlusion of Doubly Committed Subarterial Ventricular Septal Defect Using the Amplatzer Duct Occluder-II in Children

Backgrounds

The traditional treatment of doubly committed subarterial ventricular septal defect (dcVSD) is open-heart surgery. This study aimed to evaluate the feasibility, safety, and outcome of transcatheter closure of small dcVSD using Amplatzer duct occluder-II (ADO-II) in children.

Methods

Between January 2016 and April 2021, 24 children (17 male and 7 female patients) with small dcVSD who received transfemoral closure with ADO-II were enrolled retrospectively. All of their available clinical and follow-up data were evaluated.

Results

The patients' median age was 3.2 years (1.6–12.6 years, 4.2 ± 3.1 years) and body weight was 13.3 kg (10.0–38.5 kg, 16.5 ± 7.7 kg). Left ventricular angiography showed that the median dcVSD size was 2.0 mm (1.5–3.5 mm, 2.1 ± 0.6 mm). The device was successfully implanted in 23 patients (95.8%), and one patient failed to be closed because of the underestimation of defect size due to preoperative aortic valve prolapse, with 16 patients by the antegrade approach and eight patients by retrograde approach. The diameters of the device used were 3/4, 4/4, and 5/4 mm. The median operative time was 40.0 min (20.0–75.0 min, 41.7 ± 13.7 min), and the median fluoroscopic time was 5.0 min (3.0–25.0 min, 6.8 ± 5.0 min). With a follow-up duration of 1+ to 45+ months, only 1 patient presented with new-onset mild aortic regurgitation (AR).

Conclusion

Transfemoral closure of small dcVSD with ADO-II is technically feasible and safe in the selected children. However, the development or worsening of AR requires long-term follow-up.

Risk factors for atrioventricular block after occlusion for perimembranous ventricular septal defect

BACKGROUND

The risk factors for complete atrioventricular block (CAVB) after device closure of perimembranous ventricular septal defect (pmVSD) remain unclear.

OBJECTIVE

The purpose of this study was to analyze the incidence and risk factors for CAVB after device closure for pmVSD.

METHODS

We reviewed 1884 patients with pmVSD who had undergone successful device occlusion between June 2005 and January 2020. Permanent CAVB was defined as CAVB requiring implantation of a permanent pacemaker (PPM) or extraction of the occluder.

RESULTS

In total, 14 patients (0.7%) developed permanent CAVB. Of these patients, 10 (0.5%) required PPM implantation. Four permanent CAVB occurred within 7 days after the procedure (acute), 2 between 7 and 30 days (subacute), 3 between 30 days and 1 year (late), and 5 more than 1 year (very late). None of the subacute, late, and very late CAVB recovered normal conduction with medication and eventually required device removal or PPM implantation. Four patients with acute CAVB and 1 with subacute CAVB underwent device removal, and 4 (80%) recovered normal conduction. Multivariate regression revealed that the ratio of device to defect size was the only independent risk factor for permanent CAVB (odds ratio 3.027; 95% confidence interval 1.476-6.209; P = .003).

CONCLUSION

The incidences of permanent CAVB after occlusion for pmVSD and PPM implantation were 0.7% and 0.5%, respectively. The ratio of device to defect size was the only independent risk factor for permanent CAVB. Device removal is an effective therapeutic modality for recovering normal conduction in acute and subacute CAVB patients.

Perimembranous ventricular septal defect closure via ultra-minimal trans intercostal incision in children

AIMS

This study aimed to investigate the safety, feasibility and, availability of perimembranous ventricular septal defect (PmVSD) closure via a left parasternal ultra-minimal trans intercostal incision in children.

METHODS AND RESULTS

From January 2015 to January 2019, 131 children with restrictive PmVSDs were enrolled in this study and successfully done in 126 patients (96.18%). PmVSDs were occluded via an ultra-minimal trans intercostal incision (≤1 cm), and the entire occlusive process was guided and monitored by TEE. A pericardium hanging technique was employed without sternal incision. PmVSDs were closed through a short delivery sheath assembled using a concentric occluder device. All patients were followed up for a period ranging from18 months to 24 months. Thirteen patients with PmVSD had aneurysm of membranous septum (AMS). Multistream (≥2) PmVSDs with AMS were found in 11 cases. After the operation, mild residual shunt beside the amplatzer occluder in one patient was found and had self-healing result during the 5-month follow-up period. Five patients transferred to ventricular septal defect repair operation under direct visualization with a cardiopulmonary bypass. One reason was ventricular fibrillation when guidewire passed the PmVSD, another was device dislocation, and others were the guidewire cannot pass through the PmVSD.

CONCLUSIONS

PmVSDs closure using a concentric occluder via a left parasternal ultra-minimal trans intercostal incision under TEE guidance is feasible, safe, and effective in children. This approach can be considered as an alternative treatment to open-heart surgery for restrictive PmVSDs.

Toward Routine Minimally Invasive Ventricular Septal Defect Closure Via Right Lateral Minithoracotomy

Background: Improving the surgical results and recent advancement of transcatheter techniques for closure of ventricular septal defect (VSD) increased the demand for minimally invasive approaches. In this study, we analyzed the results of the patients who underwent VSD closure with right lateral minithoracotomy (RLMT). Methods: Between September 2014 and February 2021, 24 patients underwent minimally invasive VSD closure with RLMT. The median age of the patients was 16 months (range, 4-84 months). Fifteen patients (62.5%) were female. The median weight of the patients was 9.75 kg (range, 4.6-30 kg). The types of VSD were perimembranous in 19 patients, subaortic in three patients, inlet in one patient, and subpulmonic in one patient. Five patients had low-lying pulmonary stenosis in addition to VSD. Results: No perioperative death or major complication occurred during follow-up. All defects were repaired through RLMT. The median cardiopulmonary bypass time was 81 min (range, 44-163 min), and the aortic cross-clamp time was 65 min (range, 33-131 min). The median hospital stay was 6 days (range, 5-21 days). One patient had minimal (2 mm) residual left-to-right shunt. All families were satisfied with the cosmetic results during the follow-up. Conclusions: The RLMT method is a safe and effective alternative to standard median sternotomy for VSD closure and can be performed with favorable cosmetic and clinical results.

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.

Long-term outcomes after conventional surgical repair versus perventricular device occlusion for doubly committed subarterial ventricular septal defects: a propensity score matched study

OBJECTIVES

This study aimed to investigate the long-term outcomes of perventricular device occlusion and surgical repair for doubly committed subarterial ventricular septal defect using propensity score matched analysis because previous comparative studies were limited by differences in the baseline characteristics.

METHODS

We reviewed inpatients with isolated doubly committed subarterial ventricular septal defect aged <18 years who underwent surgical repair or device occlusion between January 2011 and December 2017. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics.

RESULTS

A total of 336 patients underwent surgical repair; 99 underwent device occlusion. After matching, the repair group included 164 patients, whereas the device group had 91 patients. There were no significant differences in the baseline characteristics. The median follow-up periods were 46 and 58 months for the device and repair groups, respectively. No significant difference was noted in the rates of cumulative adverse events in the 2 groups (7.9% vs 5.5%; P = 0.61). The repair group required longer periods of hospitalization (P = 0.002) and mechanical ventilation (P = 0.016). No grade 3 or higher valvular regurgitation or high-degree atrioventricular block events were observed. All patients were in sinus rhythm at the last follow-up examination.

CONCLUSIONS

In selected patients with doubly committed subarterial ventricular septal defect, compared with conventional repair, perventricular device occlusion has comparable efficacy and safety, less invasiveness in terms of time in the hospital and on mechanical ventilation and avoidance of cardiopulmonary bypass.

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.

Percutaneous closure of perimembranous ventricular septal defect using patent ductus arteriosus occluders

OBJECTIVES

To assess the safety and efficacy of percutaneous closure of perimembranous ventricular septal defect (PmVSD) using patent ductus arteriosus (PDA) occluders.

BACKGROUND

Widespread use of conventional PmVSD closure devices has been limited by unacceptable high rate of complete heart block (CHB). The elegant design of PDA occluders is supposed to ease implantation, increase closure rate and minimize damage to adjacent structures. Thus, PDA occluders may reduce complications, especially the CHB, and offer a good alternative for PmVSD closure.

METHOD

From September 2008 to October 2015, patients who underwent attempted percutaneous VSD closure using PDA occluders were included in the study. Patient demographics, echocardiography measurements, procedure details and follow-up data until October 2017 were collected.

RESULTS

In total, 321 patients with a mean age of 15.5±12.6 years and mean a weight of 33.3±20.5 kg were included in this study. The mean defect size was 4.8±2.1 mm. Implantation was successful in 307 (95.6%) patients. The median follow-up time was 63 months (24 to 108 months). The closure rates were 89.5%, 91.5%, and 99.3% after the procedure 24 hours, 6 months and 2 years, respectively. Major complications occurred in 5 (1.7%) patients during the procedure and follow-up, including persistent CHB in 2 (0.7%) patients and device embolization in 3 (1.0%) patients. No death, disability, or other major complication was detected.

CONCLUSION

Percutaneous closure of PmVSD using PDA occluders is feasible, safe and efficacious in selected patients.

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.

Comparison of transcatheter closure, mini-invasive closure, and open-heart surgical repair for treatment of perimembranous ventricular septal defects in children: A PRISMA-compliant network meta-analysis of randomized and observational studies

OBJECTIVE

Our study was aimed to comprehensively compare the relative efficacy, safety, and the cost of transcatheter closure, mini-invasive closure, and open-heart surgical repair to treat perimembranous ventricular septal defects (pmVSDs) in children using network meta-analysis method.

METHODS

Five databases were systematically searched including Chinese Biomedical Literature Database, China National Knowledge Infrastructure, PubMed, EMBASE.com, and the Cochrane Central Register of Controlled Trials from the starting date of each database to February 2017. Tools for assessing the risk of bias in nonrandomized studies of interventions (ROBINS-I) were used to evaluate the risk of bias in observational studies and Cochrane Handbook version 5.1.0 was used for randomized controlled trials (RCTs). Data were analyzed using R-3.4.0 software and Review Manager 5.2.

RESULTS

Three RCTs and 24 observational studies were included in our study. Network meta-analysis result demonstrated that transcatheter closure was the most effective treatment in terms of operative time [standardized mean difference (SMD) = -2.02, 95% confidence interval (CI): -3.92 to -0.12], major complications [odds ratio (OR) = 0.52, 95% CI = 0.30-0.91], ICU stay (SMD = -1.11, 95% CI = -2.13 to -0.08), and hospital stay (SMD = -1.81, 95% CI = -2.24 to -1.39). However, open-heart surgical repair showed a higher success rate of the procedure than transcatheter closure (OR = 0.36, 95% CI = 0.17-0.77).Statistical analysis result demonstrated that transcatheter closure had the best potential to lessen major complications, ICU stay, hospital stay, operative time, and significant residual shunt.

CONCLUSIONS

Transcatheter closure has more benefit than mini-invasive closure and open-heart surgical repair to treat pmVSDs.

Nit-Occlud Lê VSD coil versus Duct Occluders for percutaneous perimembranous ventricular septal defect closure

OBJECTIVE

To evaluate the efficacy and safety of Nit-Occlud Lê VSD Coil versus Duct Occluders for percutaneous closure of perimembranous ventricular septal defect (pmVSD).

INTRODUCTION

VSD closure using conventional pmVSD occluders has been largely abandoned because of an unacceptable high rate of complete heart block (CHB). The advantages of Duct Occluders and VSD Coil are supposed to reduce the drawbacks of previous devices, especially CHB complications.

METHOD

Patients underwent percutaneous pmVSD closure were divided into Coil group (using VSD Coil, n = 71) and DO group (using Duct Occluders, n = 315). Patient demographics, clinical presentations, echocardiography measurements, procedure details and follow-up data were collected.

RESULT

The procedure success rate was high in both DO group (95.6%) and Coil group (97.2%, P = .53). The closure rate immediately after procedure in the DO group was higher than that in the Coil group (76.8% vs. 58.0%, P < .01). After 6 months, the closure rate was not significantly different between the 2 groups (DO group 91.3% vs. Coil group 84.1%, P = .07). The mean follow-up time was 61.4 ± 24.1 months. The major complication rate was low in both groups (DO group 1.9% vs. Coil group 1.4%, P = .78). Two patients (0.7%) in the DO group and one patient (1.4%) in the Coil group with CHB needed permanent pacemaker (P = .5). Device embolization (3 patients, 1.0%) and endocarditis (1 patient, 0.3%) occurred only in the DO group. There was no death, disability or other major complications detected in either group.

CONCLUSION

Percutaneous pmVSD closure using either Nit-Occlud Lê VSD Coil or Duct Occluders is feasible, safe and efficacious in selected patients. The main problems of Duct Occluders are unsuitable defect anatomy and device embolization while VSD Coil disadvantages are residual shunt and hemolysis.

Doubly committed ventricular septal defect closure using eccentric occluder via ultraminimal incision

OBJECTIVES

This study aimed to investigate the safety, feasibility and availability of doubly committed ventricular septal defect (DCVSD) closure via an ultraminimal intercostal incision under the guidance of transoesophageal echocardiography in children.

METHODS

From August 2014 to August 2016, 35 children with DCVSDs (≤5 mm in diameter) were enrolled in this study. A left parasternal ultraminimal intercostal incision (≤1 cm) and a pericardium hanging technique were employed without sternal incision. DCVSDs were closed through a short delivery sheath assembled with an eccentric occluder device. Transoesophageal echocardiography was used to guide and monitor the entire procedure. All patients were followed up.

RESULTS

All 35 children had complete closures with an operation success rate of 100%. The average size of DCVSDs was 3.50 ± 0.79 (range 2.2-5.0) mm, and the average device size was 5 ± 2 (range 4-9) mm. The average operation duration was 45.42 ± 11.77 (range 25-70) min, and the average hospital stay was 8 ± 2 (range 7-16) days. The median follow-up period was 17 months (range 6 months-2.5 years). Pre-existing aortic regurgitation disappeared after surgery in 1 patient and remained the same in 4 patients. No other complications were found during the operation or during follow-up.

CONCLUSIONS

Under transoesophageal echocardiography guidance, DCVSD closure using an eccentric occluder via an ultraminimal intercostal incision is feasible, safe and effective in children. The use of this approach is recommended.

Perventricular device closure of perimembranous ventricular septal defect: effectiveness of symmetric and asymmetric occluders

Objectives

To assess safety and effectiveness of symmetric and asymmetric occluders in perventricular device closure without cardiopulmonary bypass of perimembranous ventricular septal defects (pmVSDs).

Methods

The present retrospective study enrolled 581 patients who underwent perventricular device closure of pmVSDs under transoesophageal echocardiography guidance from May 2011 to April 2016, and outpatient electrocardiography and transthoracic echocardiography assessments at 1, 3, 6 and 12 months, and yearly thereafter.

Results

The overall success rate of device implantation was 92.6% (43 surgical conversions immediately). Between patients receiving symmetric ( n  = 353) and asymmetric ( n  = 185) occluders, there were no significant differences in age, weight and defect diameter distributions; however, both before discharge and at mean 28.6 ± 21.2 (range, 1-60)-month follow-up, the symmetric group had lower rates of trivial residual shunt (5.7% vs 11.4%, P  = 0.018; and 0.8% vs 5.9%, P  = 0.001) and bundle branch block (0.8% vs 5.4%, P  = 0.002; and 0.6% vs 3.8%, P  = 0.009); and at follow-up, the asymmetric group had lower residual shunt (47.6% vs 85.0%, P  = 0.020) and similar branch block (30.0% vs 33.3%, P  = 1.000) disappearance rates. There were no severe complications, i.e. aortic regurgitation, malignant arrhythmias, haemolysis or device dislocation.

Conclusions

Perventricular device closure of pmVSDs appears safe and effective with symmetric and asymmetric occluders. However, the lower residual shunt disappearance and higher branch block incidence rates for asymmetric occluders would favour more proactive conversion to surgical repair immediately when residual shunt is present intraoperatively.

Transcatheter closure, mini-invasive closure and open-heart surgical repair for treatment of perimembranous ventricular septal defects in children: a protocol for a network meta-analysis

INTRODUCTION

Both transcatheter device closure and surgical repair are effective treatments with excellent midterm outcomes for perimembranous ventricular septal defects (pmVSDs) in children. The mini-invasive periventricular device occlusion technique has become prevalent in research and application, but evidence is limited for the assessment of transcatheter closure, mini-invasive closure and open-heart surgical repair. This study comprehensively compares the efficacy, safety and costs of transcatheter closure, mini-invasive closure and open-heart surgical repair for treatment of pmVSDs in children using Bayesian network meta-analysis.

METHODS AND ANALYSIS

A systematic search will be performed using Chinese Biomedical Literature Database, China National Knowledge Infrastructure, PubMed, EMBASE.com and the Cochrane Central Register of Controlled Trials to include random controlled trials, prospective or retrospective cohort studies comparing the efficacy, safety and costs of transcatheter closure, mini-invasive closure and open-heart surgical repair. The risk of bias for the included prospective or retrospective cohort studies will be evaluated according to the risk of bias in non-randomised studies of interventions (ROBINS-I). For random controlled trials, we will use risk of bias tool from Cochrane Handbook version 5.1.0. A Bayesian network meta-analysis will be conducted using R-3.3.2 software.

ETHICS AND DISSEMINATION

Ethical approval and patient consent are not required since this study is a network meta-analysis based on published trials. The results of this network meta-analysis will be submitted to a peer-reviewed journal for publication.

PROTOCOL REGISTRATION NUMBER

CRD42016053352.

Transfemoral Device Occlusion and Minimally Invasive Surgical Repair for Doubly Committed Subarterial Ventricular Septal Defects

Transfemoral device occlusion and minimally invasive surgical repair are performed for doubly committed subarterial ventricular septal defect (dcVSD) to reduce the invasiveness of the conventional surgical repair through a median sternotomy. However, few studies have compared them in terms of effectiveness and cost. Inpatients with isolated dcVSD who had undergone transfemoral device occlusion or minimally invasive surgical repair from January 2011 to June 2014 were reviewed for a comparative investigation between the two procedures. Procedure success was achieved in 36 transfemoral (75 %) and in 36 surgical (100 %) procedures (p = 0.001). Transfemoral patients were older, with a VSD size similar to that of surgical patients (14.5 ± 11.7 vs 4.4 ± 2.9 years, p < 0.001; 4.5 ± 1.5 vs 4.4 ± 1.3 mm, p = 0.577, respectively). No significant difference was observed in complication rates between the two treatment groups (p = 1). No large residual shunt was observed. Small residual shunt was noted in two transfemoral patients and four surgical patients (p = 0.674). All these small residual shunts closed spontaneously during follow-up. The surgical repair costs 26 % less than the device occlusion (Yuan 22063.2 ± 343.9 vs Yuan 29970.1 ± 1335.2, p < 0.001), where most of the cost was attributed to the occluder in the amount of Yuan 19,500. Compared with device occlusion, minimally invasive surgical repair can provide superior efficacy and comparable complication rates. In addition, it is 26 % cheaper than device occlusion. In low-income countries where healthcare resources are limited, medical resources must be judiciously allocated to the treatment that allows for effective treatment of the largest number of patients.

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.

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.