Novel transcatheter closure of an iatrogenic perimembranous ventricular septal defect

Iatrogenic membranous ventricular septal defects (VSD) are rare complications of cardiothoracic surgery, most commonly seen as a complication of aortic valve replacements. An iatrogenic VSD can lead to right sided heart failure, systemic hypoxia, and arrhythmias, and closure is often necessary. Given the increased mortality associated with repeat surgical procedures, percutaneous transcatheter closure of these iatrogenic VSDs has increasingly become the preferred choice of therapy. We describe the first case of iatrogenic membranous VSD in the setting of mitral valve replacement and tricuspid valve repair, using the newly approved Amplatzer Duct Occluder II Device from an entirely retrograde approach. © 2014 Wiley Periodicals, Inc.     

介入治疗膜周部室间隔缺损后早期的心律失常

目的探讨介入治疗膜周部室间隔缺损后早期心律失常的特点。方法回顾性分析膜周部室间隔缺损273例心电图资料，了解介入封堵术后早期发生的各种类型心律失常。分析封堵器类型、缺损大小及有无膜部瘤对心律失常发生的影响。结果心律失常发生率33．0％（90／273），其中传导阻滞占68．9％（62／90）。国产和进口封堵器组的心律失常差异无统计学意义（P〉0．05）；室间隔缺损小于5mm组和不小于5mm组的心律失常发生率分别为25．8％、49．4％（P〈0．05）。结论膜周部室间隔缺损介入治疗后早期心律失常发生率较高，以传导阻滞为主。室间隔缺损大小和有无膜部瘤是影响术后早期心律失常的重要因素。     

介入治疗膜周部室间隔缺损后早期的心律失常

目的探讨介入治疗膜周部室间隔缺损后早期心律失常的特点。方法回顾性分析膜周部室间隔缺损273例心电图资料，了解介入封堵术后早期发生的各种类型心律失常。分析封堵器类型、缺损大小及有无膜部瘤对心律失常发生的影响。结果心律失常发生率33．0％（90／273），其中传导阻滞占68．9％（62／90）。国产和进口封堵器组的心律失常差异无统计学意义（P〉0．05）；室间隔缺损小于5mm组和不小于5mm组的心律失常发生率分别为25．8％、49．4％（P〈0．05）。结论膜周部室间隔缺损介入治疗后早期心律失常发生率较高，以传导阻滞为主。室间隔缺损大小和有无膜部瘤是影响术后早期心律失常的重要因素。     

Transcatheter closure of perimembranous ventricular septal defects using umbrella devices.

There is only limited experience of interventional closure of perimembranous ventricular septal defects (pmVSDs), particularly on the long-term follow-up. This is a report on our long-term results after transcatheter closure of pmVSDs using the Cardioseal, Starflex, or Rashkind devices. PATIENTS: Between 1993 and 2005, we performed interventional occlusions of pmVSDs in 18 patients. The size of the defect ranged between 4 and 8.5 mm, Q(p)/Q(s) was calculated between 1.3 and 2.2. Except for two, the patients had no other structural heart defect. In the early days, we used the Rashkind PDA occluder (17 mm) in seven, followed by the Cardioseal device (17 mm) in nine, and the 23 mm Starflex device in two patients. RESULTS: Interventional closure of the defects was performed successfully in all patients without any complication during the procedure. Fluoroscopy times were 11.8-53.7 min (median 28.65 min). We achieved a complete closure in 13 patients, three patients with recently implanted devices still show minimal shunting. In two patients the occluder had to be removed surgically because of embolization into the pulmonary artery and significant residual shunting resulting in severe hemolysis in the second patient. In long- (mean 10.7 years) and short-term (mean 0.85 years) follow-up we have not observed any hemolysis, arrhythmias, device dislocations, or device-related aortic or tricuspid regurgitation. CONCLUSION: Transcatheter closure of small pmVSDs using non-selfcentering devices can be performed successfully. Long-term follow-up investigations show encouraging results. Complications like device-embolization and significant residual shunting occur in the presence of large defects and/or concomitant malformations.     

Heart block and empirical therapy after transcatheter closure of perimembranous ventricular septal defect.

Two patients with perimembranous ventricular septal defects (VSDs) and inlet extension have undergone uncomplicated transcatheter device closure using the Amplatzer membranous VSD device. Both patients developed complete heart block 2-4 days from the closure. Both patients responded well to high-dose intravenous therapy with steroids and high-dose oral anti-inflammatory aspirin. Both patients remain in normal sinus rhythm 8 weeks and 10 months, respectively, from the episode.     

Mechanisms of closure of perimembranous ventricular septal defect

Although more defects in the muscular ventricular septum close spontaneously than do defects abutting on the membranous septum (perimembranous defects), a good proportion of the latter show a tendency to diminish in size and to close. The mechanism responsible for this closure is usually described as an aneurysm of the membranous septum, although some doubt has been cast as to whether this is the precise mechanism. In this study, 69 unoperated hearts with ventricular septal defect were examined; 26 (38%) showed some evidence of partial closure and none extended exclusively into the outlet part of the septum. Two thirds of the trabecular perimembranous defects, almost half of the inlet defects, and one third of the confluent defects showed signs of partial occlusion. The anatomic structures most frequently responsible were reduplication of tricuspid valve tissue (16 cases), adhesion of tricuspid valve leaflets (6 cases), and prolapse of an aortic valve leaflet (3 cases). Only in 2 cases were subaortic tissue tags observed which might have originated from the remnant of the membranous septum. The present study shows that although anatomic evidence of partial closure was present in two fifths of the hearts studied, only rarely was it due to so-called aneurysm of the membranous septum.     

应用Amplazter封堵器治疗膜周部室间隔缺损的进展

膜周部室间隔缺损（室缺）是最常见的先天性心脏病。自从本世纪初Amplatzer膜周型封堵器被广泛应用于膜周部室缺介入封堵治疗。同时新型改良设计的Amplatzer封堵器陆续问世,以及多种Amplazter封堵器非常规应用于膜周部室缺封堵,并开展了大量的临床应用研究。目前由于应用初代Amplatzer膜周型封堵器后近期或远期完全性房室传导阻滞并发症发生率较高,许多中心放弃了对其继续研究应用。对于完全性房室阻滞的机制深入探究以及封堵器选择应用进一步优化,将使Amplatzer封堵器在临床中具有广泛的应用空间,并为膜周部室缺的介入封堵治疗提供了新的思路。     

国产封堵器治疗先天性膜周部室间隔缺损的疗效评估

目的 评价应用国产封堵器治疗先天性膜周部室间隔缺损(pmVSD)的近期疗效和安全性.方法 选择2001年12月至2008年12月在上海长海医院心内科使用国产封堵器治疗的pmVSD患者604例.所有患者术后1周每天观察临床症状并行12导联心电图检查,术后3～7 d复查经胸超声心动图(TTE)和X线胸片.结果 604例患者中封堵成功576例,共置入封堵器583枚,放弃封堵28例,手术成功率95.4%.无感染性心内膜炎、血栓栓塞、猝死等并发症发生.81例患者术后出现不同类型的传导阻滞,其中右束支传导阻滞56例,左束支传导阻滞14例.31例患者在术后出现一过性的加速性室性自主心律.完全性房室传导阻滞(cAVB)11例,9例在3周内恢复,2例安置永久性心脏起搏器,其中1例术前有一过性cAVB,另1例为同时封堵房间隔缺损并室间隔缺损的患者.术后即刻,69例(12.0%)有微量-少量残余分流,术后7 d,31例分流完全消失,仍有38例(6.6%)存在微量-少量残余分流.术后主动脉瓣反流加重5例,2例由术前的微量加重到术后少量反流,3例由少量加重到中量;术后出现三尖瓣微-少量反流32例,中量反流3例.5例机械性溶血,其中1例持续5 d无好转,经导管取出封堵器,其余4例均在术后3～14 d恢复正常.1例术后出现股动脉假性动脉瘤,经加压包扎后消失.封堵器脱落1例,经导管取出,并成功行封堵治疗.封堵器移位1例,在原位置入另一封堵器.结论 使用国产封堵器治疗室间隔缺损成功率高,并发症少,是一种安全有效的治疗方法.     

对称型室间隔封堵器在先天性膜周部室间隔缺损介入治疗的应用

目的探讨对称型封堵器(SVSO)介入治疗膜周部室间隔缺损(PMVSD)的临床疗效。方法应用SVSO介入治疗63例PMVSD患者。结果手术技术成功率93.0%(58/63)。PMVSD直径5.1±1.9mm,PMVSD距主动脉瓣2.7±1.0mm,SVSO直径7.2±2.1mm。即刻封闭率94.8%。心律失常发生率23.8%(15/63例),心肌损伤2例,封堵器脱落1例,术后新发生的主动脉瓣关闭不全1例,右心室流出道梗阻1例。平均随访7.4±2.7个月,无残余分流、封堵器移位或破损及感染性心内膜炎等发生。结论应用SVSO介入治疗PMVSD疗效好、安全性高,但要高度重视其可能发生的并发症,尤其是要做好心律失常的防治。     

Complications associated with transcatheter closure of perimembranous ventricular septal defects

Objectives : To identify the complications associated with transcatheter closure of perimembranous ventricular septal defects (PmVSD) using the Amplazter PmVSD occluder (AGA Medical, USA). Methods : Between October 2002 and November 2006, transcatheter closure PmVSD was attempted in 210 patients and performed in 206 patients. Those patients were followed‐up for 6–24 months (mean, 10.6 ± 3.9 months) to identify the complications. Results : Device implantation was successfully accomplished in 206 of the 210 patients (98%). Serious complications such as high degree atrioventricular block (AV block), infective endocarditis, and device embolization occurred in eight cases (3.8%). Other complications including mild aortic or tricuspid regurgitation, femoral pseudoaneurysm, and femoral arteriovenous fistula occurred in four cases. Conclusions : Transcathter closure of PmVSD can be performed safely and successfully. But further studies should continue to evaluate the potential complications associated with this procedure. © 2008 Wiley‐Liss, Inc.     

经导管治疗假性室间隔膜部瘤226例临床分析

目的:评价经导管介入治疗假性室间隔膜部瘤的可行性及安全性,并总结其技术难点与临床策略。方法:226例先天性室间隔缺损伴膜部瘤形成患者,超声测量室间隔缺损直径3~15(4.25±2.71)mm,左心室造影测量室间隔缺损直径2~16(4.37±2.84)mm。应用7~10F输送鞘管从右心系统送入相应封堵器。封堵器直径为4~18(6.24±2.48)mm,封堵后15min重复左心室造影和经胸心脏超声波检查,观察封堵的即刻效果。术后连续心电监护5d。术后1、3个月定期心电图、心脏超声检查。结果:226例中220例患者封堵成功,成功率97.3%。未成功的6例中,4例因多出口囊袋状膜部瘤不能完全封堵而建议外科手术,1例因封堵器放置后影响主动脉瓣关闭,1例因严重心律失常而放弃封堵治疗。206例术后15min左心室造影、经胸心脏超声检查显示完全封堵,14例术后造影示少量分流,1~3个月后超声复查无异常分流。术中并发左、右束支传导阻滞分别为8例和12例,均为一过性,1周内恢复。X线透视时间10~65(15.2±8.8)min,操作时间35~120(42.5±16.2)min。结论:经导管采用封堵器治疗假性室间隔膜部瘤疗效好,安全性高,并发症少,临床应用前景好。技术关键在于对膜部瘤形态的判断以及封堵器的选择。     

Morphology of perimembranous ventricular septal defects: implications for transcatheter device closure

Several clinical series have reported successful closure of perimembranous ventricular septal defects using trancatether devices. This review presents the morphological aspects of ventricular septal defects focusing on perimembranous septal defects. By definition, a part of the margin of perimembranous septal defects is the area of fibrous continuity abutting the central fibrous body that bears the atrioventricular conduction bundle. Depending on the excursion of the remaining margin, these defects are in proximity to the aortic, tricuspid, or mitral valves. Defects that extend to be doubly committed and juxtaarterial are roofed by contiguity between pulmonary and aortic valves. Recognition of the proximity or distance of important structures is relevant in considering perimembranous defects for device closure.     

室间隔缺损介入治疗后并发三尖瓣返流原因的探讨

目的探讨经导管介入治疗室间隔缺损（VSD）发生三尖瓣返流的原因和预防措施。方法VSD封堵术后发生三尖瓣返流13（男7,女6）例,年龄3～12（平均5.0±2.7）岁。膜周部VSD伴膜部瘤患者11例,单纯膜周部VSD2例。其中囊袋型缺损10例,漏斗型缺损3例,VSD左室面直径为4～14（7.3±2.3）mm。结果13例患者,左心室造影测量VSD直径为4～15（7.5±2.4）mm,VSD距三尖瓣距离2.0～3.4（2.6±0.5）mm。囊袋型缺损右室面均有多个出口,其最大出口直径2～6mm。术后即刻9例有三尖瓣少量返流,1例三尖瓣少～中量返流。1例三尖瓣少量返流伴有海鸥鸣,术后24h海鸥鸣消失,3d三尖瓣已无返流。1例5岁患儿,其三尖瓣前腱索附着异常（在缺损口附近）,术后24h无三尖瓣返流,5d超声心动图发现三尖瓣前瓣腱索断裂伴中～大量返流。1例VSD直径15mm、右室面多孔、最大孔直径6mm的患者,放置了16mm封堵器,术后即刻、7d、1月无三尖瓣返流,3月新出现三尖瓣少～中量返流。结论VSD封堵治疗后发生的三尖瓣返流可能与导管损伤隔瓣腱索、输送钢丝损伤腱索、封堵器磨损腱索及封堵器本身的设计缺陷有关,应引起临床医生的高度重视     

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.     

Transesophageal echocardiographic guidance of transcatheter ventricular septal defect closure

Objectives. This report describes transesophageal echocardiographic guidance of transcatheter closure of ventricular septal defects and its value as an adjunct to fluoroscopy and angiography in this procedure.Background. Experience with transcatheter closure of ventricular septal defects has identified a diverse group of patients in whom it may be the procedure of choice. Although facilitating other interventional procedures, such as transcatheter closure of atrial septal defects, the value of transesophageal echocardiographic guidance for transcatheter ventricular septal defect closure has not been documented.Methods. All patients who underwent ventricular septal defect closure with transesophageal echocardiographic guidance before November 1992 were included. Angiograms and echocardiograms were reviewed to evaluate device position and relation to valve tissue during placement and to assess residual flow after device implantation. The ability of transesophageal echocardiography to assess these variables was compared with fluoroscopy and angiography.Results. Transesophageal echocardiographic guidance was used in 31 of the 83 catheterizations involving transcatheter ventricular septal defect closure performed between February 1990 and November 1992. Under transesophageal echocardiographic guidance, 45 devices were implanted: 23 in muscular ventricular septal defects, 17 in residual postoperative patch margin defects and 5 in other ventricular septal defects. Transesophageal echocardiographic guidance enhanced assessment of device position and proximity to valve structures and markedly improved assessment of residual flow. Assessment of residual flow with transesophageal echocardiography elimuinated the need for multiple angiograms in some patients. Combining transesophageal echocardiography with fluoroscopy and angiography provided the most information.Conclusions. Transesophageal echocardiography facilitates transcatheter closure of ventricular septal defects by improving assessment of device position and effectiveness of closure. It is indicated when device placement is likely to be difficult or may interfere with valve structures or when multiple interventional procedures are anticipated.