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

[Pulmonary hypertension in adults with congenital heart disease in light of the 2022-ESC-PAH guidelines - Part II: Supportive therapy, special situations (pregnancy, contraception, non-cardiac surgery), targeted pharmacotherapy, organ transplantation, special management (shunt lesions, left ventricular disorders, univentricular hearts), interventions, intensive care, follow-up, future perspectives]

The number of adults with congenital heart defects (CHD) is steadily rising and amounts to approximately 360,000 in Germany. CHD is often associated with pulmonary hypertension (PH), which may develop early in untreated CHD. Despite timely treatment of CHD, PH not infrequently persists or recurs in older age and is associated with significant morbidity and mortality.The revised European Society of Cardiology/European Respiratory Society 2022 guidelines for the diagnosis and treatment of PH represent a significant contribution to the optimized care of those affected. However, the topic of "adults with congenital heart disease" is addressed only relatively superficial in these guidelines. Therefore, in the present article, this topic is commented in detail from the perspective of congenital cardiology.

Device closure of residual aortopulmonary window using Konar-MF occluder device: an attractive new option

We report a case of a residual aortopulmonary window where a new Konar-MF occluder device was used to close the defect. This device has a low profile and conforms to the anatomy of aortopulmonary window very nicely without unnecessary protrusion on either side. This report highlights the advantage of Konar-MF occluder device for closure of such 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.

Percutaneous Closure of Hemodynamically Significant Postoperative Residual Ventricular Septal Defects

The experience with percutaneous closure of postoperative residual ventricular septal defects (VSDs) is expanding with improved device technology and techniques. To report our experience with percutaneous closure of residual VSDs after cardiac surgeries. Retrospective clinical data review of patients who had percutaneous closure of postoperative residual VSDs at our institution between 2010 and 2022. Patients' demographics, procedural, and follow-up data were looked at. Twelve patients (50% males) with a median age of 9.2 years (range 0.9-22) were identified. Baseline surgeries were 8 tetralogy of Fallot corrections, 2 pulmonary bandings for large muscular VSD (mVSD) including 1 coarctation repair, 1 atrioventricular septal defect repair, 1 sub-aortic membrane resection-induced iatrogenic VSD, 1 isolated VSD closure, and 1 additional mVSD. Median duration between baseline surgery and percutaneous VSD closure was 2.2 years (range 0.2-8.3). Residual VSD shunting was secondary to surgical patch leakage in 8/12 patients. The median angiographic defect diameter was 6.8 mm (range 4.8-14). The defect was balloon-calibrated in 3/12 patients. Defects were tackled retrogradely in 3/9 patients. Amplatzer Membranous VSD occluder (n = 1), Lifetech Multifunctional (n = 5), Membranous (n = 1) and muscular VSD occluders (n = 2) and Occlutech Membranous (n = 1) and Muscular (n = 2) VSD occluders were used. The procedure was successful in 10/12 patients. Two devices embolized to the pulmonary artery and were snare-retrieved. Both patients were referred for surgery. The median follow-up was 1.3 years (range 0.1-12). Six-month ultrasound showed one trivial residual shunt and one mild right ventricular outflow obstruction. One patient is receiving targeted therapy for pulmonary hypertension at 2 years of follow-up. Transcatheter closure of postoperative residual VSDs is a feasible yet challenging intervention. Procedural complications can be encountered.

Word of caution: silent late device embolisation after perimembranous ventricular septal defect closure in a 6-Kg infant

We report on a 6-month-old infant (6 Kg/ 64 cm) with perimembranous ventricular septal defect (absent sub-aortic rim, 10 mm left ventricular entry, and 4 and 6 mm right ventricular exists) and successful retrograde closure using an 8x6 mm KONAR-MF™ VSD occluder (Lifetech, China). Immediate and 48 hours post-procedure ultrasounds showed an accurately positioned device and two jets of mild-to-moderate residual shunts. At the 2-week follow-up, the device did not change position and the shunt was stable and intra-prosthetic. The scheduled 3-month follow-up was skipped for familial reasons. The patient came back without alarming symptoms for the regular 6-month follow-up, and the device was found embolised to the left pulmonary artery. The device was retrieved surgically, and the defect was patch-closed with excellent outcomes. There was a pseudoaneurysm involving the tricuspid valve chordae and the device was endothelialized partially on one edge suggesting that embolization occurred somewhere between 3 months and 6 months post-operative. Defects with compromised anatomies should be closed surgically to avoid suboptimal results, especially in small infants.

Transcatheter Closure of Perimembranous Ventricular Septal Defects Including Multifenestrated and Gerbode-Type Defects Using the Lifetech Konar Device

(1) Transcatheter closure of perimembranous ventricular septal defects (PmVSD) is becoming more attractive and effective with the development of new occluders. The aim of this study was to report a single-center experience in PmVSD closure using the Lifetech Konar-multifunctional occluder (MFO). (2) From March 2019 to October 2022, 43 consecutive patients were enrolled in the study. Among them, 13 had multifenestrated PmVSD including 5 Gerbode-type defects. (3) There were 23 males/20 females, and the median age was 17 years (range 2-68 years). Trivial aortic regurgitation was noticed in 19 patients. Implantation was successful in all patients under general anesthesia. A retrograde approach was used in 35 patients (81%). The retrograde approach was associated with a lower radiation dose (p = 0.042) and shorter fluoroscopy time (p = 0.002) compared to the antegrade approach. Full occlusion was observed immediately in 12 patients (28%) and in 33 patients (77%) at a median follow-up of 11 months. There were no complications such as embolization, complete atrioventricular block, device dislocation, new onset above grade I, or progression of tricuspid or aortic valve regurgitation. Seven of the thirteen patients with a multifenestrated defect had no residual shunt. The persistent shunts were all trivial intra-prosthetic leaks. (4) MFO is effective and safe for PmVSD closure including multifenestrated/Gerbode-type defects with no complication. However, a longer follow-up remains warranted to establish the safety of this technique.

Comparative outcomes of two competitive devices for retrograde closure of perimembranous ventricular septal defects

Background

Retrograde closure of perimembranous ventricular septal defects (pmVSDs) is a well-established procedure. However, interventionists are still looking for the best closure device.

Methods

We performed a single-center retrospective review of 5-year-experience (from July 2015 to July 2020) with retrograde closure of pmVSDs using AmplatzerTM Duct Occluder II (ADOII) and KONAR-MF™ VSD occluder (MFO). Deficient sub-aortic rim (SAR) (≤2.5 mm for MFO and ≤3 mm for ADOII) was an exclusion criterion in defects with a diameter ratio (right-side exit/left-side entry) > 0.5.

Results

We identified 77 patients (57.1% males) with a median age of 4.3 years (IQR, 2.2-8.3) and a median weight of 16 kg (IQR, 11.2-24.5). 44 (57.1%) defects (22.7% with deficient SARs) with a median left-side defect diameter of 8.7 mm (IQR, 5.7-10) were closed with ADOIIs. 33 (42.9%) defects (51.5% with deficient SARs) with a median left-side defect diameter of 10.8 mm (IQR, 8.8-13.5) were closed with MFOs. One 7/5 MFO was removed before release and upsized to a 12/10 MFO. Implantation success rate was 100% with ADOII and 90.9% with MFO devices. Two MFOs were snare-recaptured after embolization, and one 9/7 MFO was snare-retrieved for a new onset of grade-2 aortic regurgitation that persisted afterward. Median follow-up was 3.3 years (IQR, 2.1-4.2) for ADOII and 2.3 years (IQR, 1.7-2.5) for MFO. No permanent heart block or death occurred. Freedom from left ventricular dilation was 94.62% at 36 months of follow-up. Freedom from residual shunt was 90.62% for MFO and 89.61% for ADOII at 24 months of follow-up. One 2.6-year-old patient with baseline mild aortic valve prolapse and trivial aortic regurgitation developed a grade-2 aortic regurgitation after 9/7 MFO implantation. He was treated surgically after two years without device extraction. One new grade-2 asymptomatic tricuspid regurgitation persisted at the last follow-up in the ADOII group.

Conclusions

ADOII and MFO are complementary devices for effective retrograde closure of pmVSDs in children, including defects with absent or deficient SAR. ADOII is limited to smaller defects but offers a lower profile and a flexible left-side disk for better maneuverability over the aortic valve during retrograde implantation.

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.

Transcatheter Device Therapy and the Integration of Advanced Imaging in Congenital Heart Disease

Transcatheter device intervention is now offered as first line therapy for many congenital heart defects (CHD) which were traditionally treated with cardiac surgery. While off-label use of devices is common and appropriate, a growing number of devices are now specifically designed and approved for use in CHD. Advanced imaging is now an integral part of interventional procedures including pre-procedure planning, intra-procedural guidance, and post-procedure monitoring. There is robust societal and industrial support for research and development of CHD-specific devices, and the regulatory framework at the national and international level is patient friendly. It is against this backdrop that we review transcatheter implantable devices for CHD, the role and integration of advanced imaging, and explore the current regulatory framework for device approval.