Preoperative transcatheter closure of congenital muscular ventricular septal defects

A review of the therapeutic management of multiple ventricular septal defects

BACKGROUND AND AIM

We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes, including reinterventions, for each subset.

METHODS

We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, associated anomalies, and the effect of severe pulmonary hypertension.

RESULTS

Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between 0% and 14.2%, with morbidity estimated between 6% and 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with the need for reoperation being over four times higher. Perventricular hybrid approaches are useful for the closure of high anterior or apical defects. Overall, the results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical subsets.

CONCLUSIONS

We have addressed the approaches, and the results, of therapeutic treatment in terms of coexisting discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.

Transcatheter Closure of Perimembranous and Intracristal Ventricular Septal Defects Using Amplatzer Duct Occluder II in Children

Background

Transcatheter closure of aneurysmal perimembranous ventricular septal defect (pmVSD), pmVSD near the aortic valve, and intracristal VSD (icVSD) with symmetrical or asymmetrical ventricular septal defect occluders still presents significant challenges. We report our experience with transcatheter closure of pmVSD and icVSD using Amplatzer duct occluder II (ADO II) in children.

Method

We retrospectively analyzed all children, who presented to our hospital consecutively between March 2014 and June 2020 for attempted transcatheter closure of pmVSD or icVSD with the ADO II device. Standard safety and last-follow-up outcomes were assessed and compared.

Results

In total, 41 patients underwent transcatheter closure of VSD with the ADO II (28 in pmVSD and 13 in icVSD groups) with a median age of 3.5 years (total range: 0.9 to 12 years) and median weight of 15.0 kg (total range: 10.0 to 43.0 kg). Implantation was successful in 40/41 patients (97.5%, 27/28 in pmVSD group, 13/13 in icVSD group). One patient with mild aortic valve prolapse in pmVSD group developed new-onset moderate aortic regurgitation after a 4/4 mm ADO II was deployed; however, this resolved after the device was retrieved and successfully replaced with a 5 mm zero eccentric VSD occluder. There was no procedure-related mortality. After a median follow-up of six months (total range: 6 to 72 months), complete closure rates were 85.1% and 76.9% among pmVSD and icVSD groups, respectively. In the pmVSD group, one case of new-onset moderate tricuspid regurgitation was observed at six months, and there was one case of severe tricuspid regurgitation that had progressed from mild tricuspid regurgitation at 12 months. No serious complications were noted in the icVSD group.

Conclusion

ADO II provides a safe and reproducible alternative for the closure of perimembranous and intracristal ventricular septal defects with a diameter less than 5 mm in young children.

Update on shunt closure in neonates and infants

Introduction: Cardiac defects that result in shunting are the most common types of congenital heart anomalies. Although these lesions can be simple, they can cause significant hemodynamic changes and can be challenging to manage in neonates and infants. Over the recent decades, the development of new transcatheter techniques and devices has made it safe and feasible to manage such defects when indicated, even in the smallest of patients. Understanding these interventional procedures is essential in order to manage those patients.Areas covered: In this article, we review the techniques and experience for closure of atrial septal defects, ventricular septal defects, patent ductus aarteriosus,as well as coronary arteriovenous malformations and fistulas in neonates and infants. Literature review of PubMed articles was performed through January 2021, with focus on the latest data and results of the usage of interventional techniques in treating these lesions specifically in this age-group.Expert opinion: Significant shunting lesions can be particularly challenging to manage in neonates and infants. Newer lower profile devices will likely continue to be developed in the future, allowing their use for transcatheter interventions in even smaller patients and those with more complex anatomy.

Stabbed Through The Heart: An Unusual VSD Presentation

Traumatic ventricular septal defects due to penetrating cardiac injury are uncommon. Transthoracic echocardiography is an essential tool in diagnosis. Options for closure include either surgical or percutaneous repair. We present a case of a trauma-related ventricular septal defect in a young patient that was successfully repaired by using a percutaneous approach. (Level of difficulty: Intermediate.).

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.

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.

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

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

Surgical strategies and novel alternatives for the closure of ventricular septal defects

A variety of therapies are available to close ventricular septal defects (VSDs). These include surgical closure on bypass, percutaneous device closure, as well as perventricular hybrid closure. Due to the incidence of heart block (1-5%) associated with percutaneous device closure of perimembranous VSDs, surgical closure presently remains the gold standard and preferred therapy for these defects. Therapeutic options are more varied for muscular VSDs. Beyond infancy, transcatheter closure offers excellent results with low morbidity and mortality, without the need for cardiopulmonary bypass. Infants however have a higher incidence of adverse events using a percutaneous approach. Large mid-muscular VSDs in infants can be treated successfully using a hybrid approach, surgical closure on bypass or a percutaneous approach. However, VSDs located apically or anteriorly are difficult to identify surgically and for these infants, perventricular hybrid closure should be considered as the preferred therapeutic modality. However, some VSD's also can be closed percutaneously.

Clinical Experience of Transcatheter Closure for Residual Ventricular Septal Defect in Pediatric Patients

BACKGROUND

Open cardiac surgery has traditionally been the gold standard for repair of ventricular septal defect (VSD). The inherent risks and complications associated with open surgery and the incidence of postoperative residual VSD are significant disadvantages of the open surgical approach.

OBJECTIVE

To evaluate the methodology and efficacy of transcatheter closure of postoperative residual VSD in children.

METHODS

Patients with postoperative VSD who underwent percutaneous device closure in the period from August 2010 and February 2014 in our center were analyzed retrospectively. Twelve children, including 8 males and 4 females, with mean age of 8.13 ± 5.39 years (range 0.67-17 years) and mean weight of 29.63 ± 20.86 kg (range 5.5-66 kg) were included in the study.

RESULTS

Ten cases had residual shunts situated at the margin of the patches while the other two had residual shunts because of multiple muscular VSD. The mean VSD diameter was 3.84 ± 1.86 mm (range 2.3-8.7 mm). On cardiac catheterization, the reported mean pulmonary circulatory blood volume/systemic circulation volume (Qp/Qs) ratio was 1.86 ± 0.91 (range 1.1-4.25) and the mean pulmonary artery pressure was 25.92 ± 12.42 mm Hg (range 7-52 mm Hg). Successful transcatheter closure was obtained in all twelve patients with postsurgery residual VSD. Two cases with residual muscular VSD underwent retrograde catheterization via the femoral artery while one case with residual VSD located at the lower margin of the patch was accessed via the internal jugular vein. The mean procedure time was 81.25 ± 25.86 minutes (range 40-120 minutes). There was no evidence of residual VSD, and no instances of new-onset valvular regurgitation were reported, with the only two exceptions being patients who had multiple muscular VSDs where clinically insignificant residual shunts were detected.

CONCLUSION

Our retrospective study highlights the potential safety and therapeutic efficacy of transcatheter approach for closing postoperative residual VSD in children.

RECOMMENDATIONS

More robust studies with longer-term follow-up of outcomes are required to firmly establish the safety profile and respective indications for use of various occluder devices for treating different categories of residual VSD.

Closure of a large perimembranous ventricular septal defect in a 4.8 kg baby with Down syndrome using a duct occluder

A 9.5-month-old boy with Down syndrome, weighing 4.8 kg, presented with history of failure to thrive. Clinically, he had symptoms and signs of congestive heart failure. His echocardiogram showed a large perimembranous ventricular septal defect (pmVSD) with some inlet extension covered by a large aneurysmal tissue with multiple right ventricular (RV) exits. Additionally, he had hypothyroidism and Hirschsprung disease. Instead of closing the VSD surgically, the VSD was successfully closed utilizing an 8 × 6 mm duct occluder. The baby remained in the intensive care unit for one night. The day after the procedure, the infant was stable and showed clinical improvement. Electrocardiogram (ECG) showed normal sinus rhythm with no evidence of heart block. Twenty-four hours later, echocardiography showed the device was in an excellent position, with a small residual leak. There was normal tricuspid valve inflow and normal aortic valve outflow with no significant valvar insufficiency. The baby was discharged after 3 days in stable condition. We believe infants with such co-morbidities which might complicate their post-operative course and prolong the intensive care unit admission, might benefit from such alternative management.

Transcatheter trans-septal antegrade closure of muscular ventricular septal defects in young children

BACKGROUND

Surgical or transcatheter closure of muscular ventricular septal defects (mVSDs) in young children may be technically challenging and associated with significant complications.

OBJECTIVE

To assess the feasibility of trans-septal antegrade closure of mVSD in a selected subset of young children.

METHODS

This is a prospective study from a single centre from July 2011 to March 2013. Nine infants and children with single or multiple mVSDs were included in the study. The median age and weight were 6 months (range 4-18 months) and 4.5 kg (range 3.8-6.2 kg), respectively. Trans-femoral trans-septal antegrade technique was used in eight children. One child was excluded from the study because of abnormally tortuous anatomy of both the femoral veins and subsequently underwent VSD device closure by the trans-jugular approach. The follow-up evaluation included chest X-ray, ECG, and echocardiogram at 1 month, 3 months, 6 months, and 1 year.

RESULTS

The defects were closed successfully in all eight patients using Amplatzer mVSD device in 5 and Amplatzer Duct Occluder II in 3. Moderate mitral regurgitation due to entrapment of the anterior mitral leaflet occurred in one patient with a posteriorly located mVSD, necessitating removal of the device, and surgical closure of the mVSD. The small additional residual mVSD in one other patient closed spontaneously during the follow-up.

CONCLUSIONS

Transcatheter trans-septal antegrade closure of mVSD in young children is technically feasible and merits further consideration. Symptomatic relief in multiple mVSD can be achieved after closing larger defects.

Techniques and results in the management of multiple muscular trabecular ventricular septal defects

The management of patients with multiple muscular trabecular ventricular septal defects (VSDs) remains controversial. In the past two decades, innovative techniques including a right ventricular apical infundibulotomy and transcatheter, intraoperative and perventricular device closure have been exploited, and essential right atrial approach and limited apical left ventriculotomy have also been refined. However, specific management guidelines for this difficult disease have not been established. In this article, the benefits and drawbacks of each technique are reviewed and discussed. Primary repair for infants with multiple muscular trabecular VSDs was associated with good late outcomes. The right atrial approach was satisfactory for all muscular VSDs, excluding apical defects that were well seen through a limited apical ventriculotomy. Surgical closure of apical defects could be achieved safely and completely in early infancy through a limited apical left ventriculotomy or a right ventricular apical infundibulotomy. Further follow-up and prudent evaluations of ventriculotomy-associated morbidities are needed. Pulmonary artery banding should be limited to a small infant with complex associated defects. Percutaneous device closure, the most desirable option, is impractical due to limitations between the delivery system and access route. Intraoperative device closure appears less successful than device closure in the catheterization laboratory. Perventricular device closure has a significant advantage of being a non-bypass procedure approach. A less invasive strategy for "true" Swiss cheese septum is needed. All may have an important role, and results obtained by using these techniques are encouraging. These hybrid approaches will promise future success on management guidelines of multiple muscular trabecular VSDs.

Transcatheter Closure of Membranous Ventricular Septal Defects-Old Problems and New Solutions

Isolated perimembranous ventricular septal defect (VSD) is the most common congenital heart defect (after bicuspid aortic valve). Surgery is considered the gold standard for the treatment of these VSDs. However, it is associated with morbidity and mortality. Less invasive techniques have been developed, and percutaneous closure of perimembranous VSDs is now considered a possible alternative to the standard surgical approach. The main problem associated with transcatheter closure of VSD is the occurrence of complete atrioventricular block and need for pacemaker implantation. Improvements in technology and design will help to reduce the occurrence of this problem in the near future.

Successful repair of multiple muscular ventricular septal defects using a unique hybrid procedure

The surgical management of multiple muscular ventricular septal defects (mVSDs) in the infant remains a challenging problem because of the presence of residual shunts and postoperative myocardial dysfunction. We present a case of successful repair of multiple mVSDs with a unique hybrid procedure combining both the perventricular closure and open surgical repair.

Transcatheter closure of perimembranous ventricular septal defect in children: safety and efficiency with symmetric and asymmetric occluders

OBJECTIVES

This study was designed to determine the safety and efficiency of asymmetric and symmetric ventricular septal occluders (AVSDOs and SVSDOs, respectively) for closure perimembranous ventricular septal defect (PMVSD) in children.

METHODS

Between January 2003 and December 2007, 142 children with PMVSD were treated with occluders (64 with AVSDOs and 78 with SVSDOs).

RESULTS

The defect diameter was 5.3 ± 1.1 mm in the AVSDO group and 5.4 ± 1.3 mm in the SVSDO group (P > 0.05). The success rates were similar between two groups [93.8% (AVSDO) vs. 94.9% (SVSDO), P > 0.05]. Two patients in the AVSDO group were switched to the SVSDO group due to residual shunts, and one patient in the SVSDO group was switched due to aortic regurgitation after deployment of the occluder. After procedure, 17 patients [seven with AVSDOs and nine with SVSDOs (P > 0.05)] developed various types of heart block (HB). Among them, 13 patients converted to the normal sinus rhythm. The remaining four cases had not recovered at the end of the study.

CONCLUSIONS

Transcatheter closure of PMVSD using both AVSDO and SVSDO was safe and effective. Development of HB was the main complication for both devices.

Transcatheter device closure of perimembranous ventricular septal defects: mid-term outcomes

Aims

The aim of this study was to evaluate the safety and efficacy of transcatheter closure for perimembranous ventricular septal defect (pmVSD) and its long-term results. The most common congenital heart condition is pmVSD. Transcatheter closure of pmVSD is a recently described technique with limited results for mid- to long-term follow-up.

Methods and results

Between June 2002 and June 2008, 848 patients with pmVSD were enrolled in our study and treated percutaneously with pmVSD occluders. All patients were followed up until December 2008, an average of 37 months. According to colour Doppler transthoracic echocardiography before the intervention and ventriculography, the average end-diastolic pmVSD size was 5.1 and 5.4 mm, respectively. Placement of the device was successful in 832 patients (98.1%) and the median device size was 8.6 mm. During follow-up, 103 adverse events (12.4%) were reported. Most adverse events were categorized as minor and there were nine major adverse events (8.7%), including two complete atrioventricular block requiring pacemaker implantation. Kaplan–Meier estimates showed >85% freedom from major or minor adverse events during a maximal follow-up of 79 months.

Conclusions

In experienced hands, transcatheter pmVSD closure can be performed safely and successfully with low morbidity and mortality. Long-term prognostic results are favourable, and the transcatheter approach provides a less-invasive alternative that may become the first choice in selected pmVSD patients.

This trial is registered with ClinicalTrials.gov, number NCT00890799.

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: shunt lesions

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with congenital heart disease, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. Part I of the guidelines includes recommendations for the care of patients with atrial septal defects, ventricular septal defects, atrioventricular septal defects and patent ductus arteriosus. Topics addressed include genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy risk, and follow-up requirements. The complete document consists of four manuscripts, which are published online in the present issue of The Canadian Journal of Cardiology. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

Preclinical evaluation of a new self-expanding device for closure of muscular ventricular septal defects in a pig model

OBJECTIVES

Aim of our study was the preclinical evaluation of a new self expanding device for interventional closure of muscular ventricular septal defects (mVSDs) in an acute pig model.

BACKGROUND

Devices currently in use for closure of mVSDs still have their limitations. The deployment of the disks is dependent from the expansion of the stent, which can be associated with problems for sufficient closure of the mVSDs. This was the reason for developing a modified device with only one disk

MATERIALS AND METHODS

The device was constructed in a single wire technique with a unique configured retention disk. mVSDs were created in six pigs with a specially designed punch instrument, and subsequently closed with our new device during the same session using a jugular or femoral vein approach. Potential residual shunting volumes were estimated by echocardiography and hemodynamic measurements. After closure, animals were sacrificed, and hearts were harvested for macropathologic evaluation. In two animals, MRI was performed for additional noninvasive evaluation.

RESULTS

Devices were successfully implanted in all animals with good alignment of the disk to the left ventricular septum, even if the stent was oversized. Echocardiography, hemodynamics, angiography and macropathology revealed complete closure of all mVSDs. MRI and echocardiography showed a good visibility of the device.

CONCLUSIONS

Our preclinical study shows successful closure of iatrogenic created mVSDs without residual shunting. The device is characterized by a more controlled deployment, an independent deployment of disk and waist, and a good alignment of the left ventricular disk to the muscular septum.

Transcatheter closure of congenital ventricular septal defects in adult: mid-term results and complications

INTRODUCTION

Transcatheter treatment of congenital heart defects in adult patients is dramatically changing the way in which this population is being treated. This report outlines mid-term follow-up results and complications in adult patients that underwent transcatheter VSD closure.

METHODS

The data of 40 adult patients who underwent transcatheter closure of a VSD at our institution were collected prospectively between January 2000 and June 2006. The inclusion criteria for this study were clinical and/or echocardiographic evidence of a significant left-to-right shunt through a muscular VSD (mVSD) or a perimembranous VSD (pVSD). A shunt was considered significant when the following were found: (i) left atrial enlargement, defined as a left atrial-to-aortic ratio >1.5; (ii) left ventricular enlargement (left ventricular overload), defined as a left ventricular end-diastolic diameter >+2 standard deviation (SD) above the mean for the patient's age. Another inclusion criterion was a previous episode of endocarditis.

RESULTS

41 procedures were carried out in 40 patients; a mVSD-O was used in 22 patients and a pVSD-O in 18 patients (1 patient had two devices inserted). No deaths occurred; no procedure was aborted. A total of 6 (14.6%) complications occurred. The most frequent complication was a rhythm abnormality (n=4). No device embolization occurred. The median follow-up duration was 36 months (range: 6-81 months). No deaths or cases of endocarditis occurred. One patient who had two devices implanted because of a residual defect after a tetralogy of Fallot repair, had to be operated again 3 months after the second device implantation because of a persistent significant residual leak.

CONCLUSIONS

Greater experience, possibly of multicentre trials and long-term follow-up are required to better assess the safety and effectiveness of this procedure as an alternative to surgical approaches in adult patients.

The Amplatzer Membranous VSD Occluder and the vulnerability of the atrioventricular conduction system

Transcatheter closure of ventricular septal defects with the Amplatzer Membranous VSD Occluder has yielded promising initial results, but disturbances of conduction, including complete heart block, have been reported. We report our experience with the Amplatzer occluder in 35 patients with a median age 4.5 years, the defects being sized angiographically at 4.4 plus or minus 1.1 millimetres, with a range from 3 to 8 millimetres, and the size of the occluder varying from 4 to 12 millimetres. Over a median follow-up of 2.5 years, the rate of complete closure was 87% and 91%, at 1 and 2 years respectively, while 2 patients required surgical closure of the defect subsequent to the insertion of the device. Persistent regurgitation across the tricuspid valve related to the occluder was observed in 3 patients, and in 6 patients across the aortic valve. Abnormalities of conduction related to the procedure were noted in 7 patients, one-fifth of the cohort. The disturbances were transient in 1 patient, but permanent in 6, in one of the latter progressing after 6 months from left bundle branch block to intermittent Mobitz II second-degree atrioventricular block in association with expansion of the occluder. We conclude that transcatheter closure of perimembranous ventricular septal defects with the Amplatzer occluder is effective with limited complications, but the incidence of immediate and progressive disturbances of conduction related to the proximity of conduction tissues to the rims of the occluder stress the importance of larger and longer studies to assess the safety of this procedure.

Percutaneous closure of ventricular septal defects

BACKGROUND

Surgical closure of ventricular septal defects has been performed for many years, and is considered as the gold standard for treatment. It remains associated with morbidity and mortality. Transcatheter techniques have been developed in the last 10 years as a possible alternative to conventional surgery.

METHODS

The procedure is performed under general anaesthesia, and with continuous fluoroscopic and transesophageal echocardiographic guidance. Devices of the Amplatzer family, two in particular, have achieved a large popularity in clinical practice, and are currently the devices most commonly used to close muscular and perimembranous ventricular septal defect percutaneously.

RESULTS

Data from literature show that successful closure of muscular defects is obtained in around 96% of patients, with a rate of major complication of around 2%. Pooling data from the literature shows that successful closure of perimembranous defects is also obtained in 96% of patients, again with major acute complications in around 2%. The major problem is the occurrence of complete atrioventricular block, reported in 1.7% of subjects. Acquired defects can occur as residual leaks after surgical closure, or as consequence of myocardial infarction. There are very few data concerning percutaneous closure of postoperative residual defects. As for the surgical approach, in patients with post-myocardial defects the success rate of percutaneous closure is around 88%, with a mortality of 22%.

CONCLUSIONS

Nowadays, in experienced hands, percutaneous closure is a safe and effective procedure. In selected patients, closure of congenital or acquired muscular and perimembranous ventricular septal defects can be considered a real alternative to the standard surgical approach, with the advantage of a significantly reduced rate of mortality and complications.

Transcatheter closure of perimembranous ventricular septal defects in infants and children using the Amplatzer perimembranous ventricular septal defect occluder

There are very few published reports of the transcatheter closure of perimembranous ventricular septal defects (PMVSDs) using the Amplatzer PMVSD occluder with encouraging initial results. This report presents initial and 1-year results from 54 patients with PMVSDs who underwent transcatheter closure at 5 different institutions with the Amplatzer PMVSD occluder. Sixty-five patients with PMVSDs were enrolled at 5 European centers. Eleven of the 65 patients did not fulfill the patient selection criteria at the initial echocardiographic evaluation or at cardiac catheterization. As a result, a total of 54 patients underwent attempted transcatheter closure using the Amplatzer PMVSD occluder. The median age of the patients was 5.1+/-3.6 years (range 0.3 to 13), and the median weight 18.5+/-10.3 kg (range 5 to 45). Devices were permanently implanted in 49 of 54 patients. Complete occlusion of the communication at 1-year follow-up was observed in 46 of 49 patients (94%). Main early procedural complications included (1) device embolization (2 patients), (2) severe bradycardia with hemodynamic compromise (2 patients), and (3) Mobitz II (2:1) heart block (1 patient). Late procedural complications included complete heart block (1 patient). No other complications were observed during follow-up. In conclusion, the Amplatzer PMVSD occluder is promising device that can be used for transcatheter closure in selected patients with PMVSDs. Further studies and long-term follow-up are required before this technique enters routine clinical practice.

The anaesthetist and the cardiac catheterisation laboratory

Interventional cardiology is an innovative and expanding field. Anaesthetists are increasingly involved in managing complex congenital and acquired heart lesions in the cardiac catheterisation laboratory. This article provides an overview of common lesions encountered in the cardiac catheterisation laboratory, the anaesthetic management of patients with congenital and acquired heart lesions, the procedures performed and the complications encountered during such procedures.

Percutaneous closure of ventricular septal defects. State of the art

Ventricular septal defect (VSD) is the most common congenital heart disease. Surgery has been performed for many years and is considered to be the gold standard for the treatment of VSD. However, it is associated with morbidity and mortality. Percutaneous closure of VSDs is performed under general anesthesia and with fluoroscopic and transesophageal echocardiographic guidance. Two devices of the Amplatzer family are currently used to close percutaneously muscular and perimembranous VSD with a closure rate of 97% (incidence of major complication 2.2%) and 97.5% (major acute complications in 1.2%), respectively. Occurrence of complete atrioventricular block is reported in 1% of subjects. Acquired VSD can occur as post-surgical residual leak, as a traumatic event or as consequence of a myocardial infarction. There are few data about percutaneous closure of post-surgical residual VSD and of traumatic VSD. As for the surgical approach, in patients with post-myocardial infarction VSD success rate of percutaneous closure is around 88% with a mortality of 22%. The currently available data show that, in experienced hands, percutaneous closure is a safe and effective procedure. Device closure of muscular and perimembranous VSD is a real alternative to the standard surgical approach with the advantage of a significantly reduced rate of mortality and complications.

Device closure of muscular ventricular septal defects in infants less than one year of age using the Amplatzer devices: Feasibility and outcome

OBJECTIVES

In this study, we evaluated the feasibility, safety, and outcome of device closure of muscular ventricular septal defects (mVSD) in infants less than 1 year of age using the Amplatzer devices.

BACKGROUND

Closure of mVSDs continues to represent a surgical challenge with significant morbidity. Hence, device closure is becoming an attractive and reliable alternative. However, little is known about the feasibility of this procedure in small infants.

METHODS

Between July 1999 and September 2006, device closure of mVSD was attempted in 20 infants ranging in age from 3 days to 12 months (median +/- SD; 4.6 +/- 3.8) and in weight from 3.2 to 8.9 kg (4.6 +/- 1.9) under TEE guidance by percutaneous or hybrid (perventricular) techniques. The size of the VSD as assessed by TEE ranged from 3 to 11 mm (6.0 +/- 2.2) and the Qp:Qs ratio ranged from 0.7 to 8.8 (2.8 +/- 2.3).

RESULTS

The device was successfully placed in 19/20 infants and it ranged in size from 4 to 14 mm (8.0 +/- 2.6). It was percutaneously deployed in 11/19 and by the hybrid approach in 8/19. There were 30 devices placed in 19 infants with multiple devices placed in 5/19 infants. Fluoroscopy times ranged from 11 to 136 min (41 +/- 28) and procedure times ranged from 57 to 291 min (178 +/- 68). The success rate as defined by complete closure or a trivial shunt was 84% immediately and 100% at 1-year follow-up. Major complications occurred in 4/20 patients: wire perforation and hemopericardium (n = 1), device migration (n = 1), transient electromechanical dissociation (n = 1), and mediastinitis (n = 1). At a median follow-up of 3.8 years, all patients improved and had no hemodynamically significant VSDs. No major complications were encountered in patients with multiple devices.

CONCLUSION

In infants less than 1 year of age, percutaneous and perventricular device closure of mVSDs is technically feasible and highly effective with low morbidity. Long term safety and efficacy needs to be assessed.

Transcatheter closure of perimembranous ventricular septal defects using amplatzer asymmetric ventricular septal defect occluder: preliminary experience with 18-month follow up

BACKGROUND

This study reports our experience in the nonsurgical closure of perimembranous ventricular septal defects in children and adolescents with the Amplatzer asymmetric ventricular septal defect occluder and the outcome of an 18-month follow up.

METHODS AND RESULTS

Twenty patients (median age:10 years; median weight:32 kg) with perimembranous ventricular septal defect were selected for transcatheter closure with the Amplatzer device. The prosthesis diameter chosen was 1-2 mm larger than the largest measured diameter of the defect on transesophageal echo (TEE). All patients were put on oral aspirin (5 mg/kg/day in children and 150 mg/day in adults) five days prior to and for six months after closure. Follow-up evaluation at 48 hr and 1, 6, 12 and 18 months included clinical examination, electrocardiogram, and a transthoracic echocardiogram. The mean defect diameter on color flow mapping on TEE was 7.1 +/- 2.3 mm. The device diameter ranged from 6-14 mm (median = 8 mm). One patient developed an anaphylactic reaction to contrast. The procedure was successful in 17 out of 19 patients where it was attempted (89.4%). In two patients with associated significant aortic valve prolapse and mild aortic regurgitation the device could not be successfully deployed. A trivial residual shunt observed during postdeployment left ventricular angiogram in 7 of 17 patients (41.2%) completely disappeared at one month follow-up. Three patients had right bundle branch block (2 complete and 1 incomplete) whereas one developed junctional escape rhythm with a right bundle branch block morphology. One patient had clinically silent thromboembolism to the left vertebral artery and another patient had hemolysis which resolved spontaneously within 48 hr. Follow-up at 13.5 +/- 5.3 months (range 1-18 months) revealed no residual shunt. The left ventricular internal dimension in diastole decreased significantly from 45 +/- 6 mm to 40 +/- 6 mm (P < 0.01) at the time of the last follow up. The baseline tricuspid regurgitation (n = 4) and aortic regurgitation (n = 3) remained unchanged during the follow up period. None of the patients developed left ventricular outflow tract obstruction or new aortic or tricuspid regurgitation. There were no other device related complications such as device migration, systemic thromboembolism, infective endocarditis, pericardial effusion or delayed conduction disturbances.

CONCLUSIONS

In carefully selected children and young adults, the Amplatzer asymmetric ventricular septal defect occluder is a promising device for transcatheter closure of perimembranous ventricular septal defect with encouraging results on short term follow up.

[Ventricular septal defects: anatomic, clinical, therapeutic and prognostic aspects. 44 cases]

OBJECTIVES

The aim of this study is to analyze epidemiologic, anatomic, clinical and prognostic aspects of ventricular septal defect (VSD) in the pediatric population in Morocco.

METHODS

This retrospective descriptive study included 44 consecutive patients admitted to the cardiology B department of Rabat University Hospital Center from January 2000 through March 2003. The inclusion criteria were: VSD, isolated or associated with other left-right shunt defects, diagnosed by transthoracic echocardiography, and hospitalized in the service.

RESULTS

VSD accounted for 10.6% of the congenital cardiac diseases hospitalized in our department. Patients' mean age was 2.25 +/- 2.6 years; the consanguinity rate was 29%. The primary clinical symptoms were dominated by failure to gain weight (84%), exertional dyspnea (82%), and repeated bronchitis (72%). Early complications were infundibular stenosis (4 cases), aortic regurgitation (3 cases), and infectious endocarditis (1 case). Nine children had other abnormalities, including 6 with trisomy 21. Echocardiography showed that membranous defects were by far the most common type (88%). All patients received symptomatic medical treatment. Only 31.7% (n=14) had surgery: 11.3% (n=5) to close the hole (corrective) and 20.4% (n=9) for pulmonary artery (palliative) banding. After two years of follow-up, those with surgical correction were all doing well.

CONCLUSION

Surgically closing the VSD is the best way to avoid irreversible pulmonary arterial hypertension; banding should be only a temporary measure while awaiting corrective surgery.

Transcatheter Closure of Muscular Ventricular Septal Defect Using the Amplatzer Devices

TECHNIQUE

From November 1997 to June 2002, percutaneous transcatheter closure of muscular ventricular septal defects was attempted in seven patients. Four patients had single and three had multiple defects. Surgical closure was performed in two patients in an attempt to close a perimembranous defect, leaving behind a large apical muscular defect, which was successfully closed using a device in one patient, whilst the second patient succumbed to septicemia/endocarditis 3 weeks after failure of device implantation. One patient had previous pulmonary artery banding and in another intraoperative placement of two Clamshell devices followed by additional transcatheter closure using Gianturco coils in two different sessions was performed.

RESULTS

Transcatheter closure of ventricular septal defect was successful in six patients. Three patients underwent closure of their ventricular septal defects using the Amplatzer Septal Occluder and in the remaining three patients. Amplatzer Muscular Ventricular Septal Defect Occluder was used. The median age was 15 months (range 14 months to 10 years) and the median weight was 7.8 kg (range 7-16 kg). The devices were deployed antegradely in all patients. Immediate complete closure was obtained in three patients while two patients had small and one had a large residual following the procedure. The later was due to another multiple muscular septal defect. Transient heart block occurred in one patient during the procedure and another patient developed heart block on day 3 post-procedure. The latter required temporary pacemaker. During the follow up, one patient who had residual multiple muscular defects underwent a successful redo transcatheter closure using two Amplatzer Muscular Ventricular Septal Occluder devices.

CONCLUSIONS

We conclude that transcatheter closure of muscular ventricular septal defect using Amplatzer devices is feasible and effective.

Percutaneous closure of postoperative ventricular septal defects with the amplatzer device

The objective of this study was to look at the procedure, the results, and the follow-up of patients who underwent percutaneous closure of a residual ventricular septal defect (VSD) following a surgical closure using the Amplatzer VSD device. Four patients had an original diagnosis of tetralogy of Fallot, two patients had a patch leak following a surgical repair of a VSD, and three patients had a VSD not repaired at the time of surgery. All patients fulfilled the currently accepted surgical criterion for reoperation (Qp/Qs>1.5). The mean Qp/Qs was 1.8+/-0.3 (1.5-2.3). Four patients underwent VSD closure using an Amplatzer perimembranous VSD device and in five patients an Amplatzer muscular VSD device was implanted. We performed percutaneous closure in nine patients. The size of the residual shunt ranged from 6 to 14 mm and the size of device used ranged from 8 to 16 mm. The arteriovenous loop needed to be recreated in two patients because of failure to advance the delivery sheath. There was complete closure of the defect in six cases, and a small residual shunt remained in three cases. Percutaneous closure of postoperative VSDs appears to be an effective way to resolve a hemodynamically significant residual shunt. There were no difficulties encountered with implantation of the devices. These promising short-term results need reinforcement with additional long-term data.

Transcatheter closure of congenital ventricular septal defect with Amplatzer septal occluders

This study reports on experience with transcatheter closure of congenital ventricular septal defects (VSDs) with Amplatzer septal occluders. From January 2000 to April 2005, transcatheter Amplatzer device implantation was attempted in 122 patients with congenital VSD (30 with muscular, 87 with perimembranous, and 5 with residual postsurgical repair of conotruncal malformations). Patient mean age was 15 years (range, 6 months to 64 years), and mean weight was 35 kg (range, 5.8 to 102 kg). The VSD mean size was 7 mm (range, 4 to 16 mm), mean Qp/Qs was 2.1 (range, 1.3 to 4), and mean fluoroscopy time was 32 minutes (range, 5 to 129 minutes). All procedures were performed with the patient under general anesthesia and guided by fluoroscopy and transesophageal echocardiography. The device size chosen was usually 1- to 2-mm larger than the maximum defect size as assessed by either the echocardiographic or angiographic views that were judged most reliable. Amplatzer muscular devices were placed in 47 patients, and the membranous devices were placed in 72 patients. The procedure was not performed in 3 patients with perimembranous VSD because of the impossibility of achieving an adequate long sheath position in 1 patient, onset of complete atrioventricular (AV) block during catheter manipulation in 1 patient, and the presence of aortic valve prolapse preventing a safe device placement in 1 patient. Satisfactory device implantation was achieved in 119 of 122 patients (97.5%): a tiny smoke-like residual flow through the device was often seen immediately after the procedure (50%); residual shunting was detectable in 19% after 24 hours and in only 4% at 6 months. The following additional catheter interventions were performed simultaneously: balloon pulmonary valvuloplasty in 3 patients, device closure of atrial septal defects in 2 patients, coil occlusion of the arterial duct in 1 patient, stenting coarctation in 1 patient, and stenting of the right pulmonary artery in 1 patient. Minimal aortic regurgitation developed in 3 patients, and minimal tricuspid regurgitation in 3 patients; no patient required additional treatment. Device embolization occurred in 3 patients (1 patient with muscular VSD, 2 with perimembranous VSD); catheter retrieval and implantation of a second device was successfully performed in all patients. Transient left bundle branch block occurred in 2 patients, and transient first-degree AV block in 1 patient. Among the perimembranous VSD cases, complete AV block occurred acutely (within 48 hours) in 3 patients, requiring a pacemaker in 1 patient; complete heart block occurred in the other 2 patients after 5 and 12 months, requiring pacemakers. There was no mortality. Transcatheter closure of muscular and perimembranous VSDs offers encouraging results: 96% complete closure at midterm follow-up. Complications are limited; the most relevant appears to be device-related complete heart block in perimembranous VSD. Greater experience and long-term follow-up are required to assess the safety and effectiveness of this procedure as an alternative to conventional surgery.

Arterial switch operation for transposition of the great arteries combined with closure of paramembranous ventricular septal defect using the Amplatzer membranous ventricular septal occluder

Ventricular septal defects (VSDs) complicate the arterial switch operation (ASO) in newborns with transposition of the great arteries because of prolonged cardiac arrest time and subsequent ventricular dysfunction. Three newborns with paramembranous VSDs were successfully treated using the newly designed Amplatzer membranous VSD occluder during the ASO. The implantation of a 4-mm asymmetric Amplatzer device in 2 patients and an 8-mm device in the third resulted in the complete occlusion of the septal defects. The cardiac arrest time for anatomic repair might be effectively reduced by this new approach in pediatric cardiac surgery.

Percutaneous closure of congenital and acquired ventricular septal defects--considerations on selection of the occlusion device

Nonsurgical closure of congenital and acquired ventricular septal defects (VSD) has become increasingly acceptable with the availability of various occlusion systems that allow percutaneous treatment of muscular and membranous defects. This study describes a series of 12 patients (0.2-74-years-old) who underwent defect closure with six different occlusion systems. Device selection according to anatomy and outcome is highlighted. Seven VSDs were located in the membranous part of the septum, five in the mid-muscular septum. Complex heart lesions were present in five postmyocardial infarction VSD in one and residual postsurgical defects in three patients. The size of the VSD ranged from 2.6 to 10 mm. The applied devices were: Amplatzer muscular VSD occluder (n=4), Amplatzer septal occluder (n=2), Amplatzer duct occluder (n=1), Amplatzer membranous VSD occluder (n=2), Nit-Occlud coil (n=2), and Cook PDA coil (n=1). The devices were implanted successfully in nine patients. There was complete VSD closure in eight patients within the first 24 hours. In one patient, a trivial residual shunt disappeared at 6 months follow-up. Because of device instability, two occluders were removed during catheterization. In two other cases, tricuspid valve tissue was entrapped in the occluder and had to be removed surgically, one of them during the consecutive Rastelli operation. Neither significant arrhythmia, nor thromboembolism or hemolysis occurred in out patients during follow-up. Transcatheter closure of VSD is an attractive alternative to surgery. In complex congenital heart disease, surgical-interventional hybrid therapy may improve morbidity and total outcome. The recently developed Amplatzer VSD devices allow closure of muscular and membranous VSDs. Implantation and short-term follow-up are superior to the formerly used devices. Long-term effects have to be evaluated in further studies.

Catheter closure of perimembranous/membranous ventricular septal defects using the Amplatzer occluder device

Perimembranous ventricular septal effects (PMVSDs) are the most common congenital cardiac defects of clinical importance. During the last decade, transcatheter closure of PMVSDs has been attempted using various occluders with variable success. This article reviews the existing literature and our experience with transcatheter closure of PMVSDs with the new Amplatzer occluder device.

Outcome of transcatheter closure of muscular ventricular septal defects with the Amplatzer ventricular septal defect occluder

OBJECTIVES

To present further experience and intermediate term outcome in 30 patients with single muscular ventricular septal defects (MVSDs) who underwent transcatheter closure with the Amplatzer ventricular septal defect occluder (AVSDO).

PATIENTS AND DESIGN

Thirty patients, aged 4 months to 16 years, with MVSDs underwent transcatheter closure with the AVSDO. The device consists of two low profile disks made of Nitinol wire mesh with a 7 mm connecting waist. The prosthesis size (waist diameter) was selected to be equal to the balloon "stretched" diameter of the defect. A 7-9 French sheath was used to deliver the AVSDO. Fluoroscopy and transoesophageal echocardiography guided the procedure.

RESULTS

The stretched diameter of the defects ranged from 6-14 mm. The communication was completely occluded in 28 of 30 patients (93% closure rate). One patient (a 4 month old infant) with sustained complete left bundle branch block after the procedure went on to develop complete heart block one year later. No other complications were observed during a mean follow up of 2.2 years (range 0.25-4.5 years).

CONCLUSIONS

The AVSDO is an efficient prosthesis that can be safely used in the majority of patients with a single MVSD. Further studies are required to establish long term results in a larger patient population.

Pediatric interventional catheterization: reasonable expectations and outcomes

This article considers the role transcatheter therapy plays in the treatment of each major type of congenital heart lesion. The focus is on the clinical ramifications of the interventions rather than their technical aspects.

Transcatheter Device Closure of Congenital and Postoperative Residual Ventricular Septal Defects

Background— Our purpose was to describe a 13-year experience with patients undergoing transcatheter device closure of unrepaired congenital or postoperative residual ventricular septal defects (VSDs).

Methods and Results— Since 1989, 170 patients (median age, 3.9 years) have undergone catheterization for closure of 1 or more congenital (n=92) or postoperative (n=78) residual VSDs using successive generations of STARFlex-type devices. Outcomes included echocardiographic assessment of residual flow and device position, assessment of VSD shunt/severity, and adverse events. Among 168 patients in whom device implantation was performed, between 1 and 7 devices were placed per patient (median, 1), with multiple devices placed in 40%. There was a significant decrease in left-to-right shunting after device implantation ( P <0.001) and significant improvement in VSD size/severity, and device position proved stable. Of 332 adverse events, 39 were related to the device and 261 were related to the catheterization; all but 5 occurred in the periprocedural period. At a median follow-up of 24 months (0 to 154 months), 14 patients had died and 18 had device(s) explanted.

Conclusions— Congenital and postoperative VSD closure using STARFlex-type devices resulted in stable improvement in clinical status and decreased interventricular shunting. Although periprocedural events occurred frequently, late events caused by the device were rare. Transcatheter device closure is an effective management option for patients with complex muscular VSDs that are difficult to approach surgically and for postoperative residual VSDs.