Catheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: initial clinical experience.

The surgical closure of membranous ventricular septal defects (VSDs) is associated with morbidity and low mortality. Six patients with VSDs located in the membranous part of the ventricular septum underwent an attempt of catheter closure using a new device specifically designed for the membranous septum. Patients ranged in age from 3.5 to 19 years (median, 10.5 years) and in weight from 15 to 45 kg (median, 29 kg). One patient with associated pulmonary valve stenosis had shortness of breath. The median Qp/Qs ratio was 1.6 (range, 1.1-3) and the median left ventricle end-diastolic dimension (LVEDD) was 44 mm (range, 38-52 mm). The devices were deployed via the femoral vein using 7-8 Fr sheaths. There was immediate complete closure in all patients. One patient developed trivial aortic regurgitation. There were no other complications. The median fluoroscopy time was 15.5 min (range, 10.3-53.4 min). At 24 hr, all patients were doing well. The median LVEDD decreased to 38 mm (range, 34-47 mm). One patient continued to have trace aortic regurgitation. All patients were discharged home after 24 hr. Transcatheter occlusion of membranous VSDs is safe and effective. Further clinical trials are underway to assess the long-term safety and results.     

Dose-Dependent Effects of AbobotulinumtoxinA (Dysport) on Spasticity and Active Movements in Adults With Upper Limb Spasticity: Secondary Analysis of a Phase 3 Study

Background

AbobotulinumtoxinA has beneficial effects on spasticity and active movements in hemiparetic adults with upper limb spasticity (ULS). However, evidence-based information on optimal dosing for clinical use is limited.

Blunt trauma as a risk factor for group A streptococcal necrotizing fasciitis

PURPOSE: Anecdotal reports suggest that blunt trauma and seemingly innocuous musculoskeletal injuries (e.g., muscle strains) are risk factors for developing necrotizing fasciitis (NF) and myositis caused by group A Streptococcus and other bacteria; however, this hypothesis has not been tested in analytic epidemiologic studies of invasive group A streptococcal (GAS) disease. We conducted two case-control studies to determine whether nonpenetrating trauma is a risk factor for either NF or severe cellulitis caused by GAS. METHODS: A secondary analysis of patients who were hospitalized throughout Florida for invasive GAS disease during a 4-year period was conducted. Two case series were used. The first series comprised patients who had severe GAS cellulitis. The second were patients who had GAS NF. Case-patients were compared to a single control series composed of patients with invasive GAS disease not including either NF or cellulitis (e.g., primary bacteremia, septic arthritis). RESULTS: After we adjusted for age, race, and clindamycin usage, GAS NF cases were 5.97 times as likely as controls to have a recent history of blunt trauma (p = 0.04). Patients with severe cellulitis were not more likely than controls to have associated blunt trauma. CONCLUSIONS: Nonpenetrating trauma is significantly associated with the development of GAS NF.     

Device closure of iatrogenic membranous ventricular septal defects after prosthetic aortic valve replacement using the Amplatzer membranous ventricular septal defect occluder.

Iatrogenic hemodynamically significant ventricular septal defects (VSDs) after aortic valve replacement are rare. The surgical risk to close such VSDs is substantial. Catheter closure has rarely been attempted because access to the left ventricle during cardiac catheterization in patients with a prosthetic aortic valve has been associated with a risk of catheter entrapment. We describe two cases of this rare entity after St. Jude and Medtronic valve replacement in which successful percutaneous closure of the iatrogenic VSDs was achieved using the Amplatzer membranous VSD occluder. Crossing the prosthetic valves with a delivery sheath and closure with the membranous VSD device was accomplished in both cases.     

Device Closure of Congenital Ventricular Septal Defects

Ventricular septal defect is the most common congenital heart malformation. Surgical closure, when indicated, has been practiced for over 50 years with good results; however, surgical closure is still associated with significant morbidity and mortality. Over the past decade, several occluding devices have been developed that made catheter device closure an attractive alternative to surgery with widely satisfactory results. In this article, a comprehensive review of percutaneous and perventricular (hybrid) device closure of each type of ventricular septal defect is presented.     

Transcatheter Pulmonary Valve Replacement: Current State of Art

Purpose of Review

The past couple of decades have brought tremendous advances to the field of pediatric and adult congenital heart disease (CHD). Percutaneous valve interventions are now a cornerstone of not just the congenital cardiologist treating patients with congenital heart disease, but also—and numerically more importantly—for adult interventional cardiologists treating patients with acquired heart valve disease. Transcatheter pulmonary valve replacement (tPVR) is one of the most exciting recent developments in the treatment of CHD and has evolved to become an attractive alternative to surgery in patients with right ventricular outflow tract (RVOT) dysfunction. This review aims to summarize (1) the current state of the art for tPVR, (2) the expanding indications, and (3) the technological obstacles to optimizing tPVR.

Recent Findings

Since its introduction in 2000, more than ten thousands tPVR procedures have been performed worldwide. Although the indications for tPVR have been adapted earlier from those accepted for surgical intervention, they remain incompletely defined. The new imaging modalities give better assessment of cardiac anatomy and function and determine candidacy for the procedure. The procedure has been shown to be feasible and safe when performed in patients who received pulmonary conduit and or bioprosthetic valves between the right ventricle and the pulmonary artery. Fewer selected patients post trans-annular patch repair for tetralogy of Fallot may also be candidates for this technology. Size restrictions of the currently available valves limit deployment in the majority of patients post trans-annular patch repair. Newer valves and techniques are being developed that may help such patients.

Summary

Refinements and further developments of this procedure hold promise for the extension of this technology to other patient populations.

     

Novel technique to prevent prolapse of the Amplatzer septal occluder through large atrial septal defect.

We report on a new technique (holding the left atrial disk in the left atrium by a dilator) to prevent prolapse of the left atrial disk of the Amplatzer septal occluder during deployment in large atrial septal defects (ASDs). Two patients underwent successful closure of their ASDs using this new technique.     

Transcatheter closure of postinfarction ventricular septal defects using the new Amplatzer muscular VSD occluder: Results of a U.S. Registry.

The objective of this study was to assess the immediate and mid-term results of transcatheter closure of postinfarct muscular ventricular septal defects (VSDs) using the new Amplatzer postinfarct muscular VSD device (PIMVSD). Ventricular septal rupture occurs in 0.2% of myocardial infarcts and remains associated with very high morbidity and mortality. Data were prospectively collected for 18 patients who underwent attempted device closure of postinfarction VSDs between 2000 and 2003. Five patients underwent the closure in the acute phase (within 6 days from the infarct); the remaining patients underwent closure on day 14-95 after the diagnosis of the infarct. Outcome parameters included procedural success, evidence of residual shunts on echocardiography, and occurrence of procedure-related complications. The procedure was successful in deploying a device across the VSD in 16 of 18 patients. The 30-day mortality was 28%. Eleven patients are still alive and have been followed up for a median of 332 days. Two patients required a second procedure to close a residual VSD. At the most recent outpatient follow-up, the VSD was completely closed in two patients, six patients had a trivial or small residual shunt, and two patients had a moderate residual shunt. We conclude that percutaneous device closure of postinfarction VSDs using the Amplatzer PIMVSD occluder appears to be safe and effective. Further trials are required to assess long-term efficacy and compare the results with those of surgical closure.     

Transjugular melody valve placement in a small child with protein losing enteropathy

The authors present a patient with situs inversus totalis, dextrocardia, and tetralogy of Fallot with complete AV canal who underwent pulmonary valve‐sparing complete repair during infancy but developed progressive pulmonary outflow obstruction on serial follow‐up. His right ventricular outflow tract (RVOT) was prestented as a precursor for Melody valve placement. After this, he developed protein losing enteropathy (PLE) which was unresponsive to medical management. Finally, he received transcatheter Melody valve percutaneously in the pulmonic position that lead to clinical and biochemical resolution of his PLE symptoms. © 2014 Wiley Periodicals, Inc.