Complete heart block associated with device closure of perimembranous ventricular septal defects

Transcatheter Closure of Perimembranous Ventricular Septal Defect Using KONAR-MF™: A Multicenter Experience

Transcatheter closure of perimembranous ventricular septal defect (PmVSD) is an established procedure. However, the occurrence of complete heart block limits its scope. The newer KONAR-MF™ occluder has specific design characteristics that may improve the safety of PmVSD closure. The objective of the study was to describe the efficacy and mid-term follow-up of transcatheter closure of PmVSD using KONAR-MF™. The study was conducted prospectively in 3 Indian centers (January 2018-December 2022). PmVSD closure was done by both antegrade and retrograde methods, and patients were followed up at 1, 3, 6, 12 months, and annually after that. 121 out of 123 patients were included with the following characteristics: median age 4.4 (0.18-40) years; weight 15 (2.1-88) kg; mean Qp/Qs ratio 1.87 ± 0.52 and pulmonary artery mean pressure: 22 ± 6.9 mmHg. The procedure was successful in all but 3; the device was removed due to significant residual shunt (n = 2) and new development of aortic regurgitation (AR) (≥ mild) in 1. The median defect size was 5.2 (2.5-12) mm. Device sizes from 6/4 to 14/12 were deployed (median fluoroscopy time 13.3 min; range 3.6-47.8). Shunt occlusion rates were 90%-Immediate, 95%-pre-discharge, and 97%-1 month, with no instances of complete heart block after the procedure and during follow-up. Six had new onset AR (mild: 2, trivial 4), and one had increased tricuspid regurgitation. All patients were well during follow-up (median: 20 months; range: 6-46). The new KONAR-MF™ occluder appears to be a promising and safe alternative for the closure of the PmVSD; further long-term follow is merited.

Use of the Occlutech pmVSD Device for Hybrid Closure of a Large Mid-Muscular Ventricular Septal Defect in a Small Infant Born With Hypoplastic Aortic Arch

We describe the perventricular device closure of a large mid-muscular ventricular septal defect (VSD) in a 2.9 kg infant born with hypoplastic aortic arch and VSD using an Occlutech perimembranous occluder. In this case, the anatomy required a short low-profile device and hence a perimembranous occluder was used. To our knowledge, this is the first described use of this device for hybrid closure of a muscular VSD and the application of this technique in a patient <3 kg.

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.

Update on percutaneous and perventricular device closure of congenital ventricular septal defect

INTRODUCTION

Ventricular septal defect is the most common congenital heart defect. Surgical repair has been standard therapy for symptomatic ventricular septal defects since the 1950's. Catheter-based device closure of ventricular septal defects emerged in the 1980's and has become a safe and effective alternative in select patients.

AREAS COVERED

This review focuses on patient selection and procedural techniques for device closure of ventricular septal defects, including percutaneous and hybrid perventricular approaches. The available devices used for these procedures, and outcomes of their use, are reviewed.

EXPERT OPINION

Percutaneous and perventricular device closure of ventricular septal defects is safe and effective in select patients. However, the majority of ventricular septal defects requiring closure continue to be managed with conventional surgery. Further development and investigation of transcatheter and hybrid surgical approaches for closing ventricular septal defects is required.

Percutaneous Transcatheter Closure of Congenital Ventricular Septal Defects

Ventricular septal defects (VSDs) are the most common kind of congenital heart disease and, if indicated, surgical closure has been accepted as a gold-standard treatment. However, as less-invasive methods are preferred, percutaneous device closure has been developed. After the first VSD closure was performed percutaneously by Lock in 1988, both techniques and devices have developed consistently. A perventricular approach for closure of muscular VSD in small patients and the closure of perimembranous VSD using off-label devices are key remarkable developments. Even though the Amplatzer membranous VSD occluder (Abbott) could not be approved for use due to the high complete atrioventricular conduction block rate, other new devices have shown good results for closure of perimembranous VSDs. However, the transcatheter technique is slightly complicated to perform, and concerns about conduction problems after VSD closure with devices remain. There have been a few reports demonstrating successful closure of subarterial-type VSDs with Amplatzer devices, but long-term issues involving aortic valve damage have not been explored yet. In conclusion, transcatheter VSD closure should be accepted as being as effective and safe as surgery but should only be performed by experienced persons and in specialized institutes because the procedure is complex and requires different techniques. To avoid serious complications, identifying appropriate patient candidates for device closure before the procedure is very important.

Long-Term Follow-up of Transcatheter Ventricular Septal Defect Closure in Children, and Comparison of Single-Hole Versus Multi-holes Ventricular Septal Defects

Background: Evaluation of complications after transcatheter ventricular septal defect (VSD) closure in long-term follow-up and large samples of children is limited. Objectives: We compared the residual shunt after transcatheter closure in VSDs with a single hole and multiple holes, a new task that has not been done so far. Methods: This retrospective study included all patients who underwent transcatheter device closure for VSD in a tertiary cardiovascular center from 2009 to 2020. Follow-up evaluation using transthoracic echocardiography (TTE) and electrocardiogram (ECG) was performed at 1, 6, 12 months, and annually after the procedure. Results: A total of 409 patients underwent transcatheter VSD closure. The mean age was 7 years (2 - 15 years), and the median follow-up duration was 48 months (1 - 10 years). The number of patients with a singular VSD was 259 (63.4%), and those with multiple exit holes were 150 (36.6%). The incidence of a residual shunt immediately after implantation was significantly higher in VSDs with multiple holes than those with a single hole (P = 0.008). During the follow-up, the residual shunts decreased in the group of VSDs with a single hole. Forty-five patients (11%) and 16 patients (4%) had a new-onset of mild and moderate tricuspid regurgitation (TR), respectively, and it decreased dramatically over time. Only 1 patient showed a new-onset mild aortic regurgitation (AR). The most crucial complication shown in 2 patients was a persistent complete heart block. Conclusions: Ventricular septal defects with multiple exit holes are a risk factor for a residual shunt. After transcatheter VSD closure, the residual shunt in patients with a multiple-hole VSD was significantly higher (P = 0.008). Although TR may increase during the procedure, it decreases dramatically over time. Interestingly, patients who had pre-procedure tricuspid or aortic regurgitation disappeared after 2 years of the procedure. The most important complication was a complete heart block in 2 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.

Transcatheter closure of ventricular septal defects: preliminary results in children weighing 10 kg or less

INTRODUCTION

Ventricular septal defect is one of the commonest heart defect in children and closure of this defect with devices has seen a rapid progression over a period of time. The availability of new and safer devices has made the transcatheter closure of ventricular septal defect a suitable option even in young children.

AIM

The study was done to evaluate the feasibility and complications of device closure of ventricular septal defect in children weighing 10 kg or less with different types of devices.

METHODS

The present study was undertaken in a newly established dedicated Paediatric Cardiac Unit at a Tertiary Care Hospital. Relevant data were obtained retrospectively from the case files and the catheterisation records and data were analysed for first 50 patients with ventricular septal defect weighing 10 kg or less between March 2018 and March 2021.

RESULTS

Among these 50 patients selected, device closure was successfully done in 45 (90%) cases while 5 (10%) attempts were unsuccessful for various reasons. The mean weight in this study was 7.46 ± 1.89 kg (2.3-10 kg), 21 (42%) cases were females while 29 (58%) were males; mean age was 19.4 ± 11.88 months (4-48 months). Right heart catheterisation study showed 21 (42%) patients with normal pulmonary artery pressures (no pulmonary artery hypertension). Among 29 patients with pulmonary arterial hypertension, 13 patients (22%) were having mild pulmonary arterial hypertension, 4 (8%) were with moderate pulmonary arterial hypertension, and 12 (24%) were with severe pulmonary arterial hypertension. Mean Qp/Qs was 2.73 ± 0.72 (2.5-4.5) and mean pulmonary vascular resistance was 1.5 ± 1.04 (0.6-4.6 WU). Amplatzer Duct Occluder (ADOI) was used in 15 (30%) cases, 27 (52%) cases were closed with Amplatzer Duct Occluder (ADOII), and the 3 (6%) cases closure was done with Amplatzer muscular ventricular septal defect occluder.

CONCLUSIONS

Transcatheter closure of ventricular septal defect in children 10 kg or less is feasible and safe alternative to surgical ventricular septal defect closure. The immediate and short-term outcomes have proven this method to be safe and valid.

Percutaneous closure of ventricular septal defect using LifeTechTM Konar-MF VSD Occluder: initial and short-term multi-institutional results

BACKGROUND

Transcatheter ventricular septal defect closure remains a complex procedure with potential complications like complete heart block and aortic regurgitation. The ideal device design for such intervention is still evolving.

AIM

To assess the safety, efficacy, and short-term outcome of ventricular septal defect closure using LifeTechTM multifunctional (KONAR-MFTM) VSD Occluder.

PATIENTS AND METHODS

In a multicenre study, 44 patients with haemodynamically significant, restrictive ventricular septal defects underwent closure with the KONAR-MFTM device from April, 2019 to March, 2020. Clinical, echocardiographic, and angiographic data were collected and reviewed. Patients were followed up at 1, 3, 6, and 12 months.

RESULTS

The median age and weight were 8 (1.7-36) years and 20 (11-79) kg. Of 44 patients, 8 (18%) had a high muscular and 36 (82%) had a perimembranous defect, of which 6 had mild prolapse of the right coronary cusp. The median ventricular septal defect size was 8.8 (3.9-13.4) mm. A retrograde approach was adopted in 39 (88.6%) patients. Nine patients (20.5%) had a small residual leak and there was a slight increase in aortic regurgitation in one patient. One device, which embolised to pulmonary artery was retrieved, and the defect was closed with a larger device. At a median follow-up of 13 (5-18) months, the residual leak persisted in 1 (2.3%) patient. Mild aortic regurgitation in one patient remained unchanged. There were no major complications.

CONCLUSION

Percutaneous closure of ventricular septal defect using KONAR-MFTM device is safe and effective in short and midterm follow-up including selected patients with perimembranous defect and mild prolapse of the right coronary cusp.

Finite Element Analysis and Bench Testing of Ventricular Septal Defect Occluder

Complications after transcatheter closure of the ventricular septal defect (VSD) is significantly associated with the mechanical behaviour of the VSD occluder. This study aims to investigate the effect of structural parameters of the VSD occluder. A mechanical model of the VSD occluder was constructed by theoretical modelling. The mechanical properties of the VSD occluders with different braiding angles (30°, 45°, 60°), materials (nitinol (NiTi), polydioxanone (PDO)) and waist-heights (3 mm, 4 mm) were analysed and validated by bench tests. For the 30°NiTi, 45°NiTi, 60°NiTi and 45°PDO occluders, the bending angles at the waist under 1 mm radial shrinkage were 112°, 121°, 155° and 155°, respectively. And the maximum principal strains at the waist were 16.62%, 8.19%, 1.20%, and 0.66%, respectively. The maximum radial deformations with 0.5 rad axial bending at the waist were 1.73, 1.44, 0.41 and 1.68 mm, respectively. When the occluders were implanted into VSD with the mean thickness of 3.5 mm, high stress appeared at the margin and the contact area, and the area with the 3-mm-occluder was much larger. In conclusion, the 60°NiTi occluder showed better ability to fit the deformation of the defect than the other NiTi occluders, and the 45°PDO occluder performed better under compression conditions but poorly under bending conditions than the 45°NiTi occluder. The choice of the appropriate waist-height is beneficial to eliminate associative complication by reducing the contact stress.

Mapping the Conduction System in Patients Undergoing Transcatheter Device Closure of Perimembranous Ventricular Septal Defect: A Proof-of-Concept Study

Earlier studies that investigated the relation of atrioventricular (AV) conduction system to perimembranous ventricular septal defect (pmVSD) were based on cardiopathological specimens. To study the relationship of conduction system to pmVSD using 3-dimensional electroanatomic mapping system (EAMS) in patients undergoing device closure. Fifteen consecutive cases of pmVSD from January 2014 to July 2017 (age > 2 years and weight > 8 kg) were included in the study. The course of conduction system and its relationship with the pmVSD was mapped before and after device closure, with the use of EAMS. Median age and weight of the cohort was 10 years (range 4-21 years) and 25 kg (range 13-55) respectively. Device implantation was successful in all patients except 1. The course and relation of the conduction system were posteroinferior to the pmVSD in all cases (100%), and away from the defect in 67% (10/15). In patient with baseline RBBB, the right-sided conduction system was in close proximity to the pmVSD. Two patients had part of left-sided conduction system in close proximity to pmVSD or device edges. Two patients developed RBBB following device deployment, which reverted to normal on follow up. No patient developed high grade AV block during the median follow-up of 34 months (range 24-62). This experimental study has shown the feasibility of 3D EAM of conduction system during device closure of pmVSD. This novel concept can be utilized to understand the anatomy of conduction system in other congenital heart diseases.

Transcatheter Closure of Perimembranous Ventricular Septal Defect Using the Lifetech Konar-Multi Functional Occluder: Early to Midterm Results of the Indonesian Multicenter Study

Background:

The alternative device to close perimembranous ventricular septal defect (pmVSD) has been searched for better result, less complications and applicable for infants. However, the ideal device is still unavailable. We aimed to evaluate the effectiveness and outcome of transcatheter pmVSD closure using the KONAR-multi functional occluder (MFO).

Methods:

Clinical, procedural, follow-up data of pmVSD patients with symptom of heart failure or evidence of significant left to right shunt, growth failure, recurrent respiratory tract infection, and history of endocarditis who underwent transcatheter closure using the MFO were prospectively evaluated.

Results:

Between January 2016 and December 2017, there were complete records of 132 pmVSD children closed using MFO from eleven centers in Indonesia. The median of age was 4.5 (0.3–17.4) years; weight 14.8 (3.5–57) kg, defect size at the smallest part 3.4 (1.0–8.1) mm, flow ratio 1.6 (1.3–4.9), mean pulmonary artery pressure 18 (7–79) mmHg, fluoroscopy time 18 (3.8–91) and procedural time 75 (26–290) minutes. A retrograde approach was done in 41 (31%) patients. Procedures succeeded in first attempt in 126 (95.4%), failed in three and migration in three patients. Six of eight infants with congestive heart failure were closed successfully. Of 126 patients with successful VSD closure, 12 months follow-up were completed in all patients. The rate of complete occlusion at 1 month, 3 months, 6 months and 12 months after intervention were 95.2%, 97.6%, 99.2%, and 99.2%, respectively. New-onset aortic regurgitation and moderate tricuspid regurgitation developed only in five and three patients. Neither complete atrioventricular block, nor other complications occurred.

Conclusion:

Transcatheter closure of pmVSD using the MFO is safe, effective, and feasible in infants and children.

Influence of percutaneous catheter intervention for congenital perimembranous ventricular septal defects in children on the cardiac conduction system and associated risk factors: a meta-analysis

Background

The aim of this study was to investigate adverse outcomes and risk factors for the cardiac conduction system in children with perimembranous ventricular septal defects (pmVSDs) who had been treated by catheter intervention.

Method

PubMed, EMBASE, Web of Science, and the Cochrane Library were searched for studies in English on interventional treatment of pmVSDs in pediatric patients published up to the end of October 15, 2020. We used random- or fixed-effect models to obtain pooled estimates of the success rate and postoperative complications.

Results

A total of 1650 pediatric patients from 8 publications were included, with a mean age ranging from 3.44 to 8.67 years old. The pooled estimate of successful implantation was 98.2% (95% CI 97.1–99.4%, I² = 69.4%; P < 0.001), and the incidence of cardiac conduction system complications was 17.4% (95% CI 8.4–26.4%, I² = 96.1%; P < 0.001), among which the incidence of heart block was 14.8% (95% CI 6.4–23.3%, I² = 96.9%; P = 0.001). The incidence of impulse formation disorders was 4.1% (95% CI 0.7–7.6%, I² = 91.7%; P = 0.019), and the incidence of complete atrioventricular block was 0.8% (95% CI 0.3–13%, I² = 0.0%; P = 0.001). Risk factors for newly emerging arrhythmias included the VSD size MD = 0.89 (95% CI 0.46–1.32, I² = 0%; P < 0.0001) and device size MD = 1.26 (95% CI 0.78–1.73, I² = 0%; P < 0.00001).

Conclusions

Percutaneous catheter intervention is safe and effective in treating pediatric patients with pmVSD, and the risk factors leading to arrhythmias include the sizes of the pmVSD and device.

Transcarotid Approach to Ventricular Septal Defect Closure in Small Infants

Perimembranous ventricular septal defect closure in small infants has traditionally been a surgically treated defect, although alternative hybrid strategies are emerging. We aim to describe a novel approach to retrograde device closure of clinically relevant perimembranous ventricular septal defects in small infants via carotid cutdown. A retrospective review of all patients managed with attempted carotid cutdown for device closure of a perimembranous ventricular septal defect was recorded at a single tertiary cardiac centre. We summarized data on successful device deployment, conversion to open repair, complications, and length of stay. Eighteen infants with median (IQR) age of 7 months (5-9 months) and weight of 7.1 kg (6.5-7.8 kg) with clinically relevant PMVSD underwent attempted retrograde closure via carotid cutdown. Median (IQR) defect size was 8 mm (7-9 mm). Successful device deployment without significant aortic or tricuspid valve interference occurred in 15 (83%) patients. Three patients were converted to open repair, one following damage to the tricuspid valve apparatus. Median (IQR) hospital stay was 1 day (1-3 days). There were no complications related to carotid cutdown. Retrograde device closure of hemodynamically significant PMVSD is feasible and effective in small infants. Decision to convert to surgical repair should be made early if suboptimal device placement occurs. Carotid evaluation should be performed to rule out any access-related complications.

Comparison of Long-Term Complications of Using Amplatzer Ductal Occluder and Ventricular Septal Defect Occluder for Transcatheter Ventricular Septal Defect Closure

Background:

Ventricular Septal Defect (VSD) is the most common type of congenital heart disease and perimembranous type is the commonest form of these defects. Trans-catheter management of these defects is a challenging procedure.

Objectives:

The purpose of this study was to compare of Trans-catheter closure of perimembranous ventricular septal defect (PMVSD) using Amplatzer Ductal Occluder (ADO) and VSD occluder and their complications and follow-up.

Patients and Methods:

Between 2013 and April 2019, 69 patients underwent percutaneous closure of PMVSD using ADO (29 patients) and VSD occluder (40 patients). After obtaining the size of VSD from the ventriculogram at least 2 mm larger than the orifice diameter of VSD at the right ventricular side was chosen. The devices were positioned after verification of the proper device position by echocardiography, aortogram and left ventriculography.

Results:

The mean age of patients were 9.07 ± 7.73 years, mean weight 26.12 ±16.25 kg. The mean defect size of the right ventricular orifice and device sizes were 5.54 ± 1.83 mm 7.72 ± 1.94 mm respectively.

Small residual shunts were seen at the completion of the procedure, but they disappeared during follow-up in all but one patient. Two patients had mild AI before the procedure in ADO group that disappeared during the follow-up. The mean follow-up period was 3.3 ± 1.7 years (range 1 to 6 years). Complete atrioventricular block (CAVB) was seen in one patient (VSD occluder) during the procedure that disappeared after the retrieval of the device. Major complication or death was not observed in our study.

Conclusions:

Trans-catheter closures of PMVSD with ADO or VSD occluder had similar effects in these patients and are safe and effective treatment associated with excellent success and closure rates. Long-term follow-up in a large number of patients is warranted.

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.

A comparison of the outcomes of dexmedetomidine and remifentanil with sufentanil-based general anesthesia in pediatric patients for the transthoracic device closure of ventricular septal defects

Objective

To compare the safety and efficacy of dexmedetomidine and remifentanil with sufentanil-based general anesthesia for the transthoracic device closure of ventricular septal defects (VSDs) in pediatric patients.

Methods

A retrospective analysis was performed on 60 children undergoing the transthoracic device closure of VSDs from January 2019 to June 2020. The patients were divided into two groups based on different anesthesia strategies, including 30 cases in group R (dexmedetomidine- and remifentanil-based general anesthesia) and 30 cases in group S (sufentanil-based general anesthesia).

Results

There was no significant difference in preoperative clinical information, hemodynamics before induction and after extubation, postoperative pain scores, or length of hospital stay between the two groups. However, the hemodynamic data of group R were significantly lower than those of group S at the time points of anesthesia induction, skin incision, thoracotomy, incision closure, and extubation. The amount of intravenous patient-controlled analgesia (PCA), the duration of mechanical ventilation, and the length of the intensive care unit (ICU) stay in group R were significantly less than those in group S.

Conclusion

Dexmedetomidine combined with remifentanil-based general anesthesia for the transthoracic device closure of VSDs in pediatric patients is safe and effective.

Echocardiographic Classification of Perimembranous Ventricular Septal Defect Guides Selection of the Occluder Design for Their Transcatheter Device Closure

BACKGROUND

Perimembranous ventricular septal defects (VSDs) has proximate relation to the aortic and tricuspid valves as well as the conduction tissues. Transcatheter closure utilizes various off-label device designs.

METHODS

Perimembranous VSD without aortic margin were classified as group A, with thick aortic margin as group B, with membranous septal aneurysm as group C and defects restricted by tricuspid valve attachments as group D. The proposed ideal design was asymmetric device in group A; duct occluder I (ADOI) and muscular ventricular septal occluder (MVSO) in group B; thin profile duct occluder II (ADOII) in group C and ADOI in group D. Device was 0-2 mm larger than the defect.

RESULTS

Eighty patients with VSD measuring 6.83 ± 2.87mm underwent successful closure. Device was retrieved before release in one group A and one group C patient due to aortic regurgitation. Asymmetric device was used in 16 group A defects. Among group B defects, ADOI was used in 5, ADOII in 5, MVSO in one and asymmetric device in 3. Group C defects were closed with ADOI in 7, ADOII in 10 and asymmetric device in 3. Three patients with multiple exits had 2 ADOII devices. Group D defects were closed using ADOI in 20 and ADOII in 10 patients. There was no late aortic regurgitation or heart block on a follow-up exceeding 7 years.

CONCLUSIONS

This echocardiographic classification helps device selection in every single patient. While asymmetric device is uniquely suited for group A defects, different designs are appropriate in the other groups.

Safety and Efficacy of Transcatheter Occlusion of Perimembranous Ventricular Septal Defect with Aortic Valve Prolapse: A Six-Year Follow-Up Study

Background

With the rapid development of transcatheter techniques and instruments, transcatheter occlusion for patients with perimembranous ventricular septal defect (pVSD) and aortic valve prolapse (AVP) was constantly being tried, while the efficacy and safety of pVSD with AVP remain controversial.

Objective

The aim of this study was to evaluate long-term efficacy and safety of transcatheter occlusion of pVSD with AVP.

Methods

We retrospectively analyzed 164 children with pVSD and AVP who underwent transcatheter occlusion between January 2013 and November 2014. AVP was divided into 3 degrees according to right coronary leaflet morphology at end-diastole during aortic root angiography. Patient demographic and clinical data were collected.

Results

There were 97 males and 67 females (median age, 40.0 (30.0–62.7) months; average weight, 16.94 ± 9.02 kg). Mild (n = 63), moderate (n = 89), and severe (n = 12) AVP success rates were 93.7%, 89.9%, and 58.3%, respectively. Immediately after procedure, there was no new-onset aortic regurgitation (AR) above trivial degree, residual shunt above mild degree, or complications requiring medication or operation, except for 1 patient who developed transient complete atrioventricular block. During follow-up, 1 mild AVP patient aggravated from mild to moderate AR and 1 moderate AVP patient aggravated from trivial to moderate AR. The new-onset AR in mild, moderate, and severe AVP was 2%, 1.8%, and 20%, respectively. AR disappeared in 17 patients. Residual shunt occurred in 9 patients after procedure, 4 of which disappeared during the follow-up period. No serious complications occurred in any patient during follow-up. Five-year cardiovascular event-free survival rates for mild, moderate, and severe AVP were 89.6%, 94.5%, and 80.0%, respectively.

Conclusion

Transcatheter occlusion of pVSD with mild and moderate AVP has a high success rate and few complications, which is safe and effective in long-term follow-up. Transcatheter occlusion of pVSD with severe AVP has low success rates and high AR incidence. Therefore, transcatheter occlusion of pVSD with AVP is recommended for mild to moderate, but not severe, AVP.

Percutaneous closure of ventricular septal defects in children: key parameters affecting patient radiation exposure

BACKGROUND

Ventricular septal defect (VSD) transcatheter closure is gaining worldwide popularity despite its complexity. Reports on key factors affecting radiation exposure in children are scarce.

AIMS

This clinical study is the first to comprehensively analyze the impact of all relevant parameters on children's radiation exposure during VSD interventional closures.

METHODS

Between March 2016 and August 2019, all pediatric VSD cases percutaneously treated at a reference center for interventional congenital cardiology and equipped with a single-plane Innova 2100 X-ray unit were retrospectively reviewed. Multiple linear regression was performed to investigate the impact of clinical, technical, and procedural parameters on patients' radiation exposure assessed using total air kerma area product (PKA,T).

RESULTS

A total of 85 patients were included in this study and 82.4% had perimembranous defects. Device implantation was successful in 96.5% of cases. The procedure lasted for a median of 60 min with a median PKA,T of 19.6 Gy.cm2 (range, 1.1 to 244.8 Gy.cm2). Patients' weight (B = 1.679, P = 0.01), number of operators (B = 1.561, P = 0.02), device positioning complexity (B = 2.381, P = 0.002), and procedural incidents (B = 2.096, P = 0.008) significantly increased PKA,T. Patients' age (B = 1.053, P = 0.784), device design (B = -1.216, P = 0.780) and approach of delivery (B = -1.119, P = 0.511) did not significantly affect PKA,T.

CONCLUSIONS

Radiation exposure in children undergoing VSD percutaneous closure was highly variable. A higher patient's weight, numbers of operators, complexity in device positioning, and procedural incidents, were identified as key factors increasing patient dose for this kind of intervention.

Short- and Long-term Outcome After Interventional VSD Closure: A Single-Center Experience in Pediatric and Adult Patients

Interventional closure of congenital ventricular septal defects (VSD) is recording a continuous rise in acceptance. Complete atrioventricular block (cAVB) and residual shunting are major concerns during follow-up, but long-term data for both are still limited. We retrospectively evaluated the outcome of patients with interventional VSD closure and focused on long-term results (> 1 year follow-up). Transcatheter VSD closures were performed between 1993 and 2015, in 149 patients requiring 155 procedures (104 perimembranous, 29 muscular, 19 residual post-surgical VSDs, and 3 with multiple defects). The following devices were used: 65 × Amplatzer™ Membranous VSD Occluder, 33 × Duct Occluder II, 27 × Muscular VSD Occluder, 3 × Duct Occluder I, 24 × PFM-Nit-Occlud®, and 3 × Rashkind-Occluder. The median age at time of implantation was 6.2 (0.01-66.1) years, median height 117 (49-188) cm, and median weight 20.9 (3.2-117) kg. Median follow-up time was 6.2 (1.1-21.3) years and closure rate was 86.2% at last follow-up. Complications resulting in device explantation include one case of cAVB with a Membranous VSD occluder 7 days after implantation and four cases due to residual shunt/malposition. Six (4%) deaths occurred during follow-up with only one procedural related death from a hybrid VSD closure. Overall, our reported results of interventional VSD closure show favorable outcomes with only one (0.7%) episode of cAVB. Interventional closure offers a good alternative to surgical closure and shows improved performance by using softer devices. However, prospective long-term data in the current era with different devices are still mandatory to assess the effectiveness and safety of this procedure.

Transcatheter device closure of ventricular septal defects in children: a retrospective study at a single cardiac center

BACKGROUND

Ventricular septal defect (VSD) is the most common congenital heart disease in the pediatric population. Nowadays, trans-catheter closure is considered a feasible method of therapy for most muscular and some perimembranous types of VSDs.

OBJECTIVE

Assess the safety, efficacy and outcome of percutaneous transcatheter closure of VSDs in children.

DESIGN

Retrospective, single center study.

SETTING

Madinah Cardiac Center, Madinah, Saudi Arabia.

PATIENTS AND METHODS

The study included all consecutive children who underwent transcatheter closure of isolated VSD during the period from December 2014 to January 2019. The data were collected from hospital database medical records. Transthoracic echocardiography (TTE) and an electrocardiogram (ECG) were done before and after the procedure in all the patients. The device was implanted by the retrograde or antegrade approach. All patients were subjected to follow-up evaluation at 1, 3, 6, 12 months, and annually thereafter with TTE and ECG.

MAIN OUTCOME MEASURES

Procedure success rate, clinical follow-up, TTE.

SAMPLE SIZE

70 children.

RESULTS

The mean (standard deviation) age of patients was 10.2 (4.1) years (range: 2-18 years), and their mean body weight was 30.9 (13.9) kg (range: 7.0-57.7 kg). Forty-eight (68.6%) children had muscular VSD (mVSD), and 22 (31.4%) children had perimembranous VSD (pmVSD). The majority of defects were closed via the retrograde approach using the Amplatzer muscular occluder device. At 24 hours after the procedure, the success rate was 90%. Only four (5.7%) cases had major adverse events including complete atrioventricular block, hemolysis, and thrombus formation.

CONCLUSION

Transcatheter closure is a safe and feasible procedure in VSDs of various morphologies, with a low adverse event rate.

LIMITATIONS

Retrospective design, single-center study, absence of control group.

CONFLICT OF INTEREST

None.

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.

Predicting the Future: Tetralogy of Fallot Will Be Primarily Treated with Catheter Based Intervention Within Two Decades. Surgeon's Perspective

Interventional cardiology has made extraordinary advances over recent years, but most are still limited to addressing single intracardiac or valvular lesions. This debate considers whether complete interventional repair of more complex congenital defects might become achievable. Tetralogy of Fallot (ToF) is probably the first candidate where complete interventional repair might be achieved-given that various components of the defect have already been successfully addressed-albeit as either a palliative intervention (RVOT stenting) or to address the sequelae of standard surgery (percutaneous PVR). This article considers the challenges that would need to be overcome in terms of the morphology of the condition, the age limitations, and the necessary technological advancements that would be required-while setting these against the benchmark of current surgical outcomes and the parallel progress that is being developed in surgical correction. While complete interventional repair of ToF may still be beyond current techniques, a hybrid approach between surgeons and intentional cardiologists can strive to create a life-long paradigm of care that minimizes the need for surgery and focuses on the maintenance of a healthy right ventricle, such that patients born with ToF can achieve normal life expectancy.

Transcatheter closure of a perimembranous ventricular septal defect with Nit-Occlud Lê VSD Coil: A French multicentre study

BACKGROUND

Transcatheter perimembranous ventricular septal defect (pmVSD) closure remains challenging and is seldom used in France given the risk of atrioventricular block (AVB). pmVSD closure with the Nit-Occlud Lê VSD coil was recently introduced in France as an alternative to occluder devices.

AIMS

To study the safety and feasibility of pmVSD closure with the Nit-Occlud Lê VSD coil.

METHODS

All consecutives cases of pmVSD closure with the Nit-Occlud Lê VSD coil in 20 tertiary French centres were included between January 2015 and December 2018.

RESULTS

Among 46 procedures in five centres, indications for pmVSD closure were left ventricle overload (76.1%), exertional dyspnoea (17.4%), history of infective endocarditis (4.3%) and mild pulmonary hypertension (2.2%). The median (interquartile [IQR]) age of the patients was 13.9 (5.7-31.8) years. Aneurismal tissue was identified in 91.3% of patients. VSD median (IQR) size was 8 (7-10) mm on the left ventricle side and 5 (4-6) mm on the right ventricle side. Implantation was successful in 40 patients (87.0%; 95% confidence interval [CI] 73.7-95.1%). Severe complications occurred in six patients (13.0%, 95% CI 4.9-26.3%), mainly severe haemolysis (8.7%, 95% CI 2.4-20.8%). One aortic valve lesion required surgical aortic valvuloplasty. Occurrence of severe complications was significantly related to the presence of haemolysis (P=0.001), residual shunt (P=0.007) and multi-exit VSD (P=0.005). Residual shunt was observed in 40% of cases with the implanted device shortly after closure and 15% after a median follow-up of 27 months. No immediate or delayed device embolization or complete AVB was recorded.

CONCLUSION

pmVSD closure with the Nit-Occlud Lê VSD Coil is feasible in older children and adults. However, residual shunting (leading to haemolysis) is a dreaded complication that should not be tolerated. pmVSD closure with the Nit-Occlud Lê VSD as a therapeutic strategy remains controversial and is limited to selected patients.

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.

Percutaneous Device Closure of Congenital Isolated Ventricular Septal Defects: A Single-Center Retrospective Database Study Amongst 412 Cases

To identify suitable cases and reduce failure/complication rates for percutaneous ventricular septal defect (VSD) closure, we aimed to (1) study causes of device failure and (2) compare outcomes with different VSD types and devices in a high-volume single center with limited resources. Retrospective data of 412 elective percutaneous VSD closure of isolated congenital VSDs between 2003 and 2017 were analyzed. Out of 412, 363 were successfully implanted, in 30 device implantation failed, and in 19 the procedure was abandoned. Outcome was assessed using echocardiography, electrocardiography, and catheterization data (before procedure, immediately after and during follow-up). Logistic regression analyses were performed to assess effects of age, VSD type, and device type and size on procedural outcome. Median [interquartile range] age and body surface area were 6.6 [4.1-10.9] years and 0.7 [0.5-1.0] m², respectively. Device failure was not associated with age (p = 0.08), type of VSD (p = 0.5), device type (p = 0.2), or device size (p = 0.1). Device failure occurred in 7.6% of patients. As device type is not related to failure rate and device failure and complication risk was not associated with age, it is justifiable to use financially beneficial ductal devices in VSD position and to consider closure of VSD with device in clinically indicated children.

Very late-onset complete atrioventricular block following deployment of Amplatzer membranous ventricular septal defect occluder

RATIONALE

Although implantation of Amplatzer membranous ventricular septal defect occluder (AVSDO) is an alternation to surgical treatment, the interventional therapy is disapproved by FDA due to high incidence of complete atrioventricular block (cAVB) post closure during early and middle term follow-up. However, long-term outcomes of the accumulating numbers of patients who had received AVSDO in the past decades, still remain an issue of concern and late occurrence of potentially catastrophic heart block long after hospital discharge is especially worrying, but rarely documented. We firstly reported a pediatric case with very late-onset cAVB occurring over ten years following transcatheter closure of PmVSD using AVSDO.

PATIENT CONCERNS

A 5-year old female received transcatheter closure of PmVSD sized 10-mm on left ventricular angiography with a 14-mm AVSDO owning to a history of recurrent lower respiratory tract infections. Post-procedure echocardiography documented no arrhythmias, residual shunt and aortic regurgitation. All electrocardiogram (ECG) recordings were completely normal and transthoracic echocardiography (TTE) examination showed the device was in the proper position and there was neither residual shunt nor valves regurgitation. Ten years after operation, the patient was re-admitted into our hospital due to recurrent syncope.

DIAGNOSES

A 12-lead ECG showed cAVB with a minimal heart rate of 42 bpm. Device flattening was revealed on 2-dimensional TTE and the occluder appeared to return to its original size and shape. Computed tomography and magnetic resonance imaging of brain did not reveal any intracranial hemorrhages, ischemic changes, or space-occupying lesions. Electroencephalogram detected no epileptiform discharge. Other possible etiologies resulting in cAVB such as myocarditis, hypothyroidism and connective tissue diseases were excluded. Therefore, it was ultimately considered the cAVB was mostly likely to be associated with device closure of PmVSD using AVSDO.

INTERVENTIONS

The child was empirically treated with prednisone (1-2 mg/Kg daily).

OUTCOMES

Unfortunately, no improvement was observed. A permanent pacemaker was implanted. The following course was uneventful.

LESSONS

For patients following transcatheter closure of PmVSD using AVSDO, the risk period for developing heart block after device closure appears to be much longer than we speculated. Long-term, perhaps and life-long followed up needs to be considered for this group of patients.

A novel biodegradable occluder for the closure of ventricular septal defects: immediate and medium-term results in a canine model

OBJECTIVES

The feasibility of an Amplatzer septal occluder closure of ventricular septal defects (VSDs) under echocardiographic guidance has already been proven. However, the technique is not used routinely owing to high-rate atrioventricular blocks and the non-absorbability of the occluder. Here, we aimed to evaluate the safety, biocompatibility and effectiveness of a new biodegradable occluder.

METHODS

A total of 18 adult beagle dogs [mean body weight 8.85 kg (range 8.10-10.40 kg)] were enrolled in our study from March 2015 to July 2018. VSD animal models were prepared by thoracic intervention, and the new bioabsorbable occluder was implanted under the guidance of transthoracic echocardiography. Laboratory examinations, transthoracic echocardiography and electrocardiography were performed after surgery, and pathological samples from dogs were obtained after euthanasia and examined in the 1st, 3rd, 6th, 9th, 12th and 24th months to evaluate the safety, biocompatibility and effectiveness of the biodegradable occluder.

RESULTS

All the dogs received successful implantations of the biodegradable occluder and survived, showing no follow-up-related complications (such as dislocation, arrhythmia and recanalization). Biochemical tests showed no significant abnormalities or differences, except for an increase in white blood cells and C-reactive proteins on the day after the operation. Histopathological examinations revealed that the bioabsorbable occluders were biocompatible, while immunohistochemical evaluations and electron microscopy showed endothelial cells growing on the occluder surface.

CONCLUSIONS

The effective occlusion of VSD, good biocompatibility, rapid endothelialization and lack of complications shown by the biodegradable occluder in this study suggest that the device meets acceptable clinical safety and has potential application prospects.

Beyond atrial septal defect closure, it is time to start seriously considering closing ventricular septal defects with devices

PURPOSE OF REVIEW

The purpose of this review is to discuss the history and current state of transcutaneous device closure of ventricular septal defects.

RECENT FINDINGS

Newer devices and techniques have expanded the role of transcutaneous device closure of ventricular septal defects. Device closure of ventricular septal defects is a mainstay of therapy in many parts of the world. Device closure in smaller infants has relatively higher risks than larger infants and older children. The potential for the development of complete heart block remains a concern with this procedure.

SUMMARY

Transcutaneous device closure of ventricular septal defects is a safe alternative to surgical repair in many patients.

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.

Device Closure of Perimembranous Ventricular Septal Defect: Choosing Between Amplatzer Occluders

Background: Off-label device closure of perimembranous ventricular septal defect (pmVSD) is well reported in the literature with encouraging results. However, technical challenges may be encountered. Objectives: To evaluate and compare feasibility, technical aspects, procedural outcomes, and mid-term follow-up of pmVSD closure using Amplatzer™ occluders. Patients and Methods: From July 2015 to July 2018, patients in whom pmVSD closure was attempted using an Amplatzer occluder were retrospectively identified from our institution's database. Device selection was made according to the defect anatomy that was obtained via ventriculography and trans-esophageal echocardiography. Follow-up evaluations were done at discharge, then at 1, 3, 6, and 12 months and yearly thereafter with transthoracic echocardiography and electrocardiogram. Results: In total, 8 Amplatzer Duct Occluder (ADO), 27 ADO II, and 17 Amplatzer Muscular VSD Occluder (AMO) were used in 51 patients with a mean age of 7.4 ± 6.9 years and a mean weight of 25.4 ± 19.8 kg. Implantation was successful in 50/51 patients (98.0%). There was no procedure related mortality. One ADO accidentally embolized to the aorta after release and was surgically recaptured from the iliac artery. All ADO II were delivered retrogradely with the least amount of time (p = 0.002) and the lowest radiation exposure (p < 0.001). Minor valvular disturbances occurred in 8/49 patients (16.3%), including five tricuspid regurgitation (three with ADOII and two with AMO) and three trivial aortic regurgitations (two with ADO and one with ADOII). On a median follow-up of 194 days (range, 60-895 days), no surgical device removal was necessary. At 6 months of follow-up, trivial residual shunt was present in 5/49 patients (10.2%), among which none occurred with ADO. One complete atrioventricular block was detected 18 months after ADO implantation and required permanent pacing. Conclusions: Transcatheter closure of PmVSD using Amplatzer occluders is feasible, safe and efficacious in properly selected patients. The major key factor behind high procedural success rate is proper device selection. ADOII is remarkably superior in terms of device softness, flexibility and faster implantation process. Yet, its use is limited to small defects with particular anatomy.

Adult Congenital Interventions in Heart Failure

Congenital heart disease (CHD) is the most common birth defect, occurring in approximately 0.8% to 1.0% of neonates. Advances in medical and surgical therapies for children with CHD have resulted in a growing population of patients reaching adulthood, with survival rates exceeding 85%. Many of these patients, especially if managed inappropriately, face the prospect of future complications including heart failure and premature death. For adults with uncorrected or previously palliated CHD, percutaneous therapies have become the primary treatment for many forms of CHD. In this article, we discuss the role of transcatheter interventions in the treatment of adults with CHD.

Late presenting complete heart block after surgical repair of ventricular septal defect

Late onset of complete heart block is a life-threatening uncommon complication after surgical repair of congenital heart diseases. In this report, we discuss two cases of Perimembranous ventricular septal defect (VSD) that had late presentation of complete heart block after surgical repair. We are aiming to highlight this unusual complication for more awareness, better understanding and management of this unusual complication after pediatric cardiac surgery.

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.

Ventricular Septal Defect Closure Devices, Techniques, and Outcomes

Transcatheter closure of ventricular septal defects (VSDs) was first documented in 1988. The early studies of VSD closure were successful but there were high complication rates, particularly early and late-onset complete heart block. However, the development and use of new vascular occlusion devices in an off-label fashion has improved the range of patients who can be treated and reduced the complication rates. In particular, the rate of complete heart block documented in contemporary studies of VSD closure has fallen to levels at or below those documented in the surgical VSD closure literature.

The Comparison of Perventricular Device Closure with Transcatheter Device Closure and the Surgical Repair via Median Sternotomy for Perimembranous Ventricular Septal Defect

Background: Perventricular and transcatheter device closures are performed for perimembranous ventricular septal defect (pmVSD) to reduce the surgical trauma of conventional surgical repair via median sternotomy. Few comparative studies have been conducted among these three procedures.

Methods: From June 2015 to May 2016, 247 patients with isolated pmVSD who had undergone perventricular or transcatheter device closure or conventional surgical repair were reviewed to compare these three procedures.

Results: The procedure success rate was similar in these three groups. There were a statistically significant difference in operative time, aortic cross-clamping time, duration of cardiopulmonary bypass (CPB), blood transfusion amount, and medical cost in these three groups. Meanwhile, postoperative mechanical ventilation time, duration of intensive care, and length of hospital stay were longer in surgical group than the other two groups. The surgical group required the longest incision. No significant difference was noted in major adverse events. There were different advantages and disadvantages in these three kinds of procedures.

Conclusions: Device closure may be alternative to conventional surgical repair for patients with isolated pmVSD. Perventricular device closure was the preferred procedure because it showed more maneuverable than transcatheter procedure with the same clinical result.

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.

Minimally invasive perventricular versus open surgical ventricular septal defect closure in infants and children: a randomised clinical trial

Background

Robust evidence is lacking regarding the clinical efficacy, safety and cardiopulmonary performance of perventricular closure. This study investigated the perioperative efficacy, safety and cardiorespiratory performance of perventricular closure of perimembranous ventricular septal defects (pmVSDs).

Methods

Operation-naïve infants and young children aged 5–60 months with isolated pmVSDs were randomised to receive either standard open surgical or minimally invasive perventricular closure via direct entry into the ventricle with a catheter from a subxiphoid incision. The primary outcomes included complete closure at discharge, major and minor adverse events and the changes in perioperative cardiorespiratory performance from baseline. Complete closure was mainly analysed in the modified intention-to-treat (mITT) population, with sensitivity analyses for the ITT, per-protocol (PP) and as-treated (AT) populations (non-inferiority margin −5.0%).

Results

We recruited 200 patients with pmVSDs for this study (mean age 24.38 months, range 7–58 months, 104 girls), of whom 100 were randomly allocated to one of the study groups. The non-inferiority of perventricular to surgical closure regarding complete closure at discharge was not shown in the ITT (absolute difference −0.010 (95% CI −0.078 to 0.058)) and mITT populations (−0.010 (95% CI −0.069 to 0.048)), but was shown in the PP (0.010 (95% CI −0.043 to 0.062)) and AT populations (0.048 (95% CI −0.009 to 0.106)). Perventricular closure reduced the rate of compromising cardiac haemodynamics, electrophysiological responses, cardiomyocyte viability, respiratory mechanics, ventilatory and gas exchange function and oxygenation and tissue perfusion compared with surgical closure (all between-group P<0.05).

Conclusions

For infants and young children with pmVSD, perventricular closure reduced the rate of postoperative cardiorespiratory compromise compared with surgical closure, but the non-inferiority regarding complete closure should be interpreted in the context of the specific population.

Trial registration number

NCT02794584 ;Results.

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.

Long-Term Outcome of Transcatheter Device Closure of Perimembranous Ventricular Septal Defects

Background: Ventricular septal defect is a common congenital heart defect. Transcatheter closure of perimembranous ventricular septal defect (pmVSD) is an effective method alternative to surgical closure. The aim of the study is to evaluate the procedural result, early and long-term follow-up outcome of transcatheter closure of pmVSD. Methods: From January 2005 to December 2016, we retrospectively identified the patients who underwent transcatheter device closure of pmVSD. All patients underwent transthoracic echocardiography (TTE) and electrocardiogram (ECG) before and after the procedure. Follow-up evaluation was done at 1, 3, 6, 12 months and yearly thereafter with TTE and ECG. Results: Total 186 patients (95 male, 91 female) had catheter-based intervention of pmVSD. The mean age at the time of procedure was 5.4 ± 2.8 years (range 2~14 years) and the mean weight was 18.1 ± 6.7 kg (range 10.5~43 kg). The mean size of the implanted device was 8.4 ± 2.1 mm (range 5~16 mm). The device was successfully implanted in 180 patients (96.8%). Immediate post-procedural echocardiography showed complete occlusion in all but one patient had trivial residual shunt. Total early adverse events occurred in 16 patients (8.9%). Only in two patients it was significant, complete AVB occurred in a 9 years old boy, managed with temporary pacemaker and one patient had complete left bundle branch block, recovered fully after steroid therapy. During a median follow-up period of 18.4 months (range 6~120 months), no serious adverse events and complete AVB were encountered. Conclusion: In our experience, The incidence of serious adverse event is low and no late onset of complete AVB with excellent success rate and follow-up results, confirming the transcatheter closure of pmVSD is a valuable alternative to surgical closure in selected patients.

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.