Initial results of primary device closure of large muscular ventricular septal defects in early infancy using perventricular access

Objectives: To report our experience with the use of the Amplatzer muscular ventricular septal defect (VSD) occluder, using direct right ventricle free wall puncture for primary closure of muscular VSDs in infants. Background: Young infants with heart failure due to large or multiple muscular VSDs often require intervention at a stage when percutaneous device closure is impractical due to delivery system limitations. There are considerable benefits to avoiding bypass in these infants. Methods: Patients with suitable muscular VSDs, considered too small for transvenous closure, underwent perventricular muscular VSD closure under transesophageal echo (TEE) guidance. Results: Eight infants underwent the procedure. The median age was 14 weeks (2–41) with median weight of 4 kg (3–6.6). Four patients had additional VSDs and one patient had previous repair of coarctation. One patient had dextrocardia and severe left ventricular impairment due to an associated cardiomyopathy. The median VSD size was 8 mm (range, 4–10 mm). A single device (6–12 mm) was deployed in each patient, the size chosen being 1–2 mm larger than the TEE measurement. Two patients had subsequent pulmonary artery banding, with absorbable bands, because of moderate residual shunting through additional VSDs. The latest echo study at a median of 7.2 weeks (0.5–66) post device implantation revealed no patients with a hemodynamically significant shunt. Conclusion: Perventricular muscular VSD closure can be safely and effectively undertaken in small infants with suitable muscular defects, and this strategy can avoid the need for bypass. © 2008 Wiley‐Liss, Inc.     

Transcatheter closure of postsurgical residual ventricular septal defects: Early and mid‐term results

Background: The incidence of residual ventricular septal defects (VSDs) after surgery is 5–25%. Redo surgery is associated with higher risks. Methods: Between January 2000 to December 2008, 170 patients underwent percutaneous VSD closure in our centre: 22(16M) of these had 23 closures for residual VSDs. Median age was 32.5 yrs (1.4–79). All patients had echocardiographic signs of left ventricle volume overload (Q_p/Q_s ≥ 1.5). Nine patients had previous VSD closure, 6 tetralogy of Fallot repair, and 7, other procedures. There were 15 muscular, 6 perimembranous and 2 apical VSDs. Results: Amplatzer VSD devices were used in all. Median VSD size was 8 mm (4.3–16). Median fluoroscopy time was 33 minutes (15–130). There were three adverse events: 1 ventricular fibrillation requiring DC cardioversion; 1 transient complete atrio‐ventricular block reverting to sinus rhythm at 24‐hours; one patient had transient atrial flutter during the procedure. All procedures were successful; no additional procedures were required. Trivial residual shunts were seen in 3 patients at follow‐up. There were no late events. One patient experienced arrhythmic death 5‐yrs after procedure. One patient was reoperated due to dehiscence of VSD patch 2‐yrs after the second successful percutaneous closure. Conclusions: Transcatheter closure of postsurgical residual VSD is safe and efficacious management option and obviates the need for further surgery and by‐pass. © 2009 Wiley‐Liss, Inc.     

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.     

Percutaneous device closure of congenital and iatrogenic ventricular septal defects in adult patients

Objectives : We report our 10‐year experience with percutaneous closure of adult congenital and acquired (non‐post‐infarct) ventricular septal defects (VSDs) using different types of Amplatzer occluder devices. Background : Adult congenital and acquired VSDs may produce significant morbidity and mortality. Furthermore, such VSDs pose a significant surgical challenge. Methods : Between February 2000 and August 2009, data were retrospectively reviewed from 28 patients who underwent 29 procedures for percutaneous device closure of hemodynamically significant VSDs. Seventeen had unrepaired congenital VSDs, 10 had post‐operative VSDs (5 with residual patch‐margin defects, 4 post‐aortic valve replacement, 1 post‐myomectomy), and one had an acquired traumatic VSD. Indications for closure included : symptoms related to significant shunt (dyspnea on exertion); unexplained deterioration of LV function, and/or LV dilation; recurrent endocarditis, and pulmonary hypertension. Outcome parameters were procedural success, procedure‐related complications, evidence of residual shunt by echocardiography, and improvement in the signs/symptoms for which the procedure was performed. The mean follow‐up interval was 68 months. Results : Of the 28 patients studied, a single VSD was present in 26 patients, while one patient had two defects, and one patient had one defect on the LV side with three openings at the RV side. The median size of the defects by echocardiography was 6 mm. A device was successfully implanted in 28 of 29 (97%) procedures and 28 of 28 (100%) patients. Procedure‐related complications occurred in two cases : one involving an access site hematoma not requiring transfusion as well as nonsustained ventricular tachycardia that resolved spontaneously and the other involving acute mitral regurgitation due to inadvertent trapping of the anterior mitral valve leaflet between the left ventricular disk and the septum that was resolved by recapturing of the disk. There was immediate complete closure in 20 patients (71%). In six cases there was trivial residual shunt and in two patients the residual shunt was mild. At the latest follow‐up, four of the eight with a residual shunt had no shunt and in the remaining four the residual shunt was trivial. Among symptomatic patients 18 (64%), there was marked improvement in symptoms and for those patients 17 (61%) for whom the procedure was performed to address left ventricular enlargement, there was reduction or stabilization in LV size on serial echoes. Conclusions : Percutaneous closure of VSDs in the adult patient appears to be safe and effective. © 2010 Wiley‐Liss, Inc.     

经食管超声心动图在微创室间隔缺损封堵治疗中的应用

目的 评价经食管超声心动图(transoesophageal echocardiography,TEE)在微创外科室间隔缺损封堵治疗中的临床价值.方法 经胸超声心动图检查粗筛27例室间隔缺损(VSD)患者,拟行微创外科非体外循环下封堵治疗.术前行TEE,根据VSD位置、类型、大小选择合适的封堵器;术中TEE引导封堵器放置,评价即刻封堵效果;术后1周内复查.结果 3例患者术前TEE剔除,20例患者封堵成功,TEE显示19例无残余分流,1例微量残余分流;4例患者转体外循环进行VSD修补,其中2例有残余分流,2例出现主动脉瓣反流;20例微创封堵成功患者术后1周内超声随访,均见封堵器位置正常,无残余分流,左心室重构改善,三尖瓣反流程度减轻,肺动脉压力下降.结论 TEE对选择适合行微创封堵的VSD患者、选择封堵器大小、协助封堵器的释放、评价疗效均有重要作用.微创VSD封堵安全、有效.     

Helex device closure of multiple atrial septal defects

Objectives : To describe the effectiveness of the Helex Septal Occluder (HSO) to close multiple atrial septal defects (mASDs). Background : Limited information is available describing closure of mASDs with the HSO. Methods : A total of 28 patients who underwent closure of mASDs with the HSO were identified by retrospective review of our catheterization database between 2001 and 2012. Procedural details and follow up information were collected. Results : Median age was 19.2 years, median weight 48 kg, with 10 (36%) patients weighing <25 kg. Indication for closure was RV enlargement (RVE) in all patients and additionally neurologic events occurred in 3/28 (11%). Median stop‐flow diameter for the largest ASD was 14 (4–23) mm. One HSO was implanted in 21/28 (75%), 2 in 6/28 (21%), and 3 in 1/28 (4%). One embolization and one transient arrhythmia occurred with no sequelae. Immediate residual shunt was absent in 5/28 (18%), trivial in 15/28 (54%), small in 6/28 (21%), and moderate in 2/28 (7%). Of the 25 patients with ≥6 months follow‐up (median 53 months), residual shunt was absent in 13/25 (52%), trivial in 5/25 (20%), and small in 7/25 (28%). RVE resolved in all but one patient with no other associated lesions and ≥6 months of follow‐up. No patient with prior neurological event had recurrence at last follow‐up. Conclusions : We conclude that closure of mASDs with ≥1 HSO is effective with a low complication rate. The ability of HSO devices to overlap or sandwich each other may facilitate safe implantation of multiple devices in smaller patients. © 2013 Wiley Periodicals, Inc.     

Simultaneous device closure of muscular ventricular septal defect and pulmonary valve balloon dilatation.

Percutaneous closure of ventricular septal defect and pulmonary valvuloplasty appears to be an attractive modality when compared to surgical treatment for both lesions. We report successful transcatheter closure of muscular ventricular septal defect with pulmonary valve balloon dilation performed simultaneously in a 27-year-old woman. Technical considerations in such a setting are being discussed.     

Perventricular device closure of muscular ventricular septal defects on the beating heart

This report describes our initial experience with intraoperative device closure of muscular ventricular septal defects under echocardiographic guidance without cardiopulmonary bypass in two patients.     

导管介入性关闭膜部室间隔缺损术后并发症(附二例报告)

１９９５年在Ｓｉｄｅｒｉｓ指导下完成经导管Ｓｉｄｅｒｉｓ钮扣式补片关闭膜部室间隔缺损２例。术后患者分别于第４、１５天出现心律不齐、主动脉瓣关闭不全、补片移位致使介入治疗失败而行手术修复。根据手术所见，虽然２例室间隔缺损介入治疗失败，但是介入治疗关闭室间隔缺损仍有重要临床价值，但在器材及操作方法上均有待进一步完善。     

导管介入或镶嵌治疗心尖部肌部室间隔缺损

目的探讨经导管介入或镶嵌治疗心尖部肌部室间隔缺损的治疗方法、疗效及随诊情况。方法选择2006年1月至2011年12月在广东省人民医院术前诊断为心尖部肌部室间隔缺损的患儿27例为研究对象,其中男18例,女9例,年龄1个月～13岁,中位年龄4.5岁。患儿分别经导管介入及镶嵌治疗,其中镶嵌治疗3例,经导管介入治疗24例。结果介入封堵组除1例因缺损小,未行治疗外,其他23例均介入治疗成功。室间隔缺损直径为(4.94±1.08)mm,选择6～10 mm肌部缺损封堵器,输送长鞘为6～9 F。镶嵌治疗组3例均成功治疗。随诊时间平均25个月。介入封堵组术后随诊有5例少量残余分流,2例中度三尖瓣反流。结论经导管介入治疗心尖部肌部室间隔缺损的疗效确切,应尽量减少三尖瓣的并发症。年龄小于1岁及体质量小于5 kg的婴儿,可考虑采用镶嵌治疗方法。     

Transcatheter coil closure of muscular ventricular septal defects

We report two patients with small, muscular ventricular septal defects, both of whom had a potential risk of infective endocarditis and underwent transcatheter closure using a detachable Cook coil. We suggest that in selected patients this technique offers a simple and cost-effective alternative to surgery or double-disc device procedures.     

Device closure of ventricular septal defects by hybrid procedures: A multicenter retrospective study

Objective : This study reports on the feasibility, efficacy, and outcome of hybrid procedures to close ventricular septal defects (VSD), reflecting the experience of 11 centers in Germany, Austria, and Switzerland. Background : Beating heart closure of VSD has attracted interest in small infants, complex anomalies and postinfarction scenarios where patients are at high risk during surgery. Perventricular or intraoperative device placement allows access to the lesions where percutaneous delivery is limited. Methods : Between December 2001 and April 2009, placement of Amplatzer septal occluders was attempted in 26 patients. The defects were located in the perimembranous (n = 5) and muscular septum (n = 21). In 20 patients, a perventricular approach was used, and, in six, the occluders were placed under direct visualization being part of a complex heart surgery. Results : In 23 of 26 procedures, device placement was successful (88.5%). The mean defect size was 7.8 mm (range, 3.5–20). The occluder types were perimembranous VSD occluder (n = 4), muscular VSD occluder (n = 20), postinfarct VSD occluder (n = 1), and ASD occluder (n = 1) with a ratio device/defect of 0.9–2.4 (median 1.15). Device removal was necessary in three due to arrhythmia, malpositioning, and additional defects. Pericardial effusion occurred once. In the remaining 22 patients, there were no procedure or device‐related complications. During mean follow up of 1.4 years (range, 1 day–3.9 years), a residual shunt that was more than trivial was observed in one patient out of 21 successful procedures. Conclusions : Perventricular and intraoperative device closure of VSD is as effective as a surgical patch and averts the increased morbidity of conventional surgical repair in a subgroup of high‐risk patients. © 2010 Wiley‐Liss, Inc.     

Successful embolization of a left ventricular pseudoaneurysm after perventricular ventricular septal defect device closure

Perventricular device closure has become an important management adjunct for ventricular septal defects deemed inoperable and difficult to address in the catheterization laboratory. Complications directly related to the procedure are rarely reported, and all have been manifest in the periprocedural period. We present the case of a 6‐week‐old boy who underwent perventricular closure of a muscular ventricular septal defect and had a left ventricle pseudoaneurysm identified 10 months later during catheterization to close residual septal defects. We describe the subsequent percutaneous coil embolization of the pseudoaneurysm and clinical follow‐up. © 2009 Wiley‐Liss, Inc.     

Transcatheter device versus surgical closure of ventricular septal defects: a clinical decision analysis.

OBJECTIVES: To compare transcatheter device versus surgical closure of ventricular septal defects (VSDs). METHODS: A clinical decision analysis was performed using standard gamble interviews. RESULTS: Device was initially preferred in 39 respondents (89%) and surgery in 5 (11%). The inherent difference in value between a perfect surgery and a perfect device (disutility of surgery) was equal to a mean risk of death of (1.2 +/- 2.2)%. Final values from decision analysis were initially equivalent. Values adjusted for estimated mortality, however, favored device (mean: 0.979 +/- 0.032) versus surgery (mean: 0.971 +/- 0.032), P = 0.052. When values were further adjusted for disutilities, device was significantly preferred (0.978 +/- 0.032) versus surgery (0.961 +/- 0.044), P < 0.005. Surgery would be preferred if the probability of major complications decreased below 5% or minor complications below 6%. CONCLUSIONS: When outcomes and their values are considered in a systematic manner, transcatheter device closure of suitable VSDs is favored over surgical repair.     

经导管纽扣式堵塞装置关闭小儿室间隔缺损临床探讨

目的为探讨经导管纽扣式堵塞装置关闭小儿室间隔缺损的疗效。方法我科从1995年1月～1997年9月采用Sideris纽扣式补片关闭小儿室间隔缺损9例。结果堵闭成功8例，失败1例，经1月～2年随访，4例恢复良好，2例有轻或中度主动脉瓣关闭不全，1例残余分流2．smm，1例中度三尖瓣关闭不全。结论本方法关闭小儿室间隔缺损，从指征，堵塞装置及操作技术上尚待进一步研究。