Transcatheter Closure of Congenital VSDs: Tips and Tricks

2019

Nowadays transcatheter device closure of ventricular septal defects (VSDs) is an attractive and feasible alternative to surgical closure of congenital VSDs. Isolated congenital VSDs constitute the most common form of congenital heart disease (CHD) in infants and children and account for 20–30% of all types of cardiac malformations. Most of the VSDs are located in the membranous portion of the ventricular septum (perimembranous VSDs). There are also less common types of VSDs located in the muscular portion (muscular VSDs), below the pulmonary valve (subpulmonary or supracristal VSDs), and near the junction of the tricuspid and mitral valves (inlet type VSDs). Indications for closure of VSDs include a hemodynamically significant left to right shunt and prevention of long-term complications, including pulmonary hypertension, progressive ventricular dilatation, aortic insufficiency, double-chambered right ventricle, and endocarditis. In this chapter, we review the technical details for ...

Circulation, 2004

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 (nϭ92) or postoperative (nϭ78) 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 (PϽ0.001) 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. (Circulation. 2004;110:501-507.)

The American Journal of Cardiology, 2005

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.

Progress in Pediatric Cardiology, 1992

Journal of Interventional Cardiology, 2004

The success with occlusion devices for the closure of atrial septal defects and patent ductus arteriosus prompted the transcatheter closure of single and multiple muscular ventricular septal defects (VSD). The procedure for VSD was first attempted by Lock et al. in 1988 and devices originally designed for the closure of other intracardiac defects (Rashkind umbrella device, Lock clamshell, Cardioseal, coils, Sideris buttoned device etc.) were used with a variable success rate and a residual shunt. Recently, specially designed Amplatzer muscular VSD occluder and Sideris device are in use. The Amplatzer muscular VSD occluder has been undergoing clinical trial since 1998 after the animal experiments had shown 100% occlusion and complete endothelization at 3 months. The procedure was first attempted in August 1995 using the Rashkind umbrella device and since April 1998 only the Amplatzer muscular VSD occluder has been used. Of the149 patients who underwent transcatheter closure of VSD, 50 had muscular trabecular defects in various locations: mid-muscular, anterior, posterior, or apical. All cases were selected by detailed transthoracic and/or transesophageal echocardiography (TTE) and aneurysm of the muscular septum was observed in three of them. The age range was 3-28 years and the diameter of VSD was 4-11 mm. In all but one patient, the device was deployed from the venous side. Simultaneous TTE was done for proper positioning of the device and continuous electrocardiographic monitoring was also done for any arrhythmia/conduction defects. All patients were followed up every 3 months and received 3-5 mg/kg aspirin for 6 months. The procedure was successful in all patients. The Rashkind umbrella device (17 mm) was used in two and Amplatzer muscular VSD occluder (6-14 mm) in 48 patients. Forty-four devices were delivered by antegrade transvenous approach and six by the transjugular route. None had residual shunt, new aortic regurgitation, or tricuspid regurgitation. Transient complete heart block after 24 hours was noticed in one patient. On a follow-up of 2-90 months, the device was in position in all patients. There was no embolization of the device, and no late-conduction defects, infective endocarditis, or hemolysis. Transcatheter closure of muscular VSD is safe and efficacious, and should be considered as a procedure of choice as an alternative to surgery that avoids cardiopulmonary bypass.

Catheterization and Cardiovascular Interventions, 2009

European Heart Journal

Aim To report the experience of 23 tertiary referral European Centres on transcatheter closure of congenital ventricular septal defects (VSD). Methods and results Implantation of transcatheter devices was attempted in 430 patients (pts) with congenital VSDs until July 2005. The following anatomic types were present: 119 muscular, 250 peri-membranous, 16 multiple, 45 residual post-surgery. Median VSD size was 7 mm (range 3–22), fluoroscopy time 33 min (range 3–146). Devices implanted were Amplatzer muscular or membranous devices in 364, PDA devices in 12, ASD devices in seven, Starflex in seven, and coils in nine patients. Procedure was suc-cessful in 410 cases (95%). Complications: device embolization in five cases (surgery in two, catheter retrieval in three), aortic regurgitation in 14 cases (two of which requiring surgery), tricuspid regurgita-tion in 27 cases (no surgery was necessary), minor rhythm disturbances in 10 pts, death in one patient, complete heart block (cAVB) in 16 ...

Journal of Interventional Cardiology, 2014

BackgroundAdvances in interventional techniques now allow for transcatheter treatment of some ventricular septal defects (VSD), although there remain concerns about adverse events. We performed a systematic review to look at outcomes and complications associated with transcatheter closure of VSD.MethodA PubMed search for series in English on device closure of VSD from 2003 to June 2012 was performed. We excluded small series that were included in multicenter studies and patients who had acquired VSD following myocardial infarction. The random effects model was used to obtain pooled estimates of success and complications.ResultsA total of 37 publications comprising 4,406 patients with VSD (perimembranous = 3,758, muscular = 419, intracristal = 47, doubly committed subarterial = 36, multiple = 16, postsurgical = 123, unclassified = 7) were included in this analysis. The age of patients ranged from 3 days to 84 years. The pooled estimate of successful device implantation was 96.6% (95%...

Journal of the American College of Cardiology, 2014

The objective of this study was to evaluate the safety and efficacy of the surgical versus transcatheter approach to correct perimembranous ventricular septal defects (pmVSDs) in a prospective, randomized, controlled clinical trial. Background pmVSD is a common congenital heart disease in children. Surgical closure of pmVSD is a well-established therapy but requires open-heart surgery with cardiopulmonary bypass. Although the transcatheter approach is associated with significant incidence of complete atrioventricular block, it may provide a less invasive alternative. Critical comparison of the safety and efficacy of the 2 interventions necessitates a prospective, randomized, controlled trial. Methods Between January 2009 and July 2010, 229 children with pmVSD were randomly assigned to surgical or transcatheter intervention. Clinical, laboratory, procedural, and follow-up data over a 2-year period were compared. Results Neither group had mortality or major complications. However, statistical analysis of the 2 groups demonstrated significant differences (p < 0.001) in minor adverse events (32 vs. 7), quantity of blood transfused, duration of the procedure, median hospital stay, median intensive care unit stay, median hospitalization cost, and median blood loss. During a median follow-up of 2 years, the left ventricular end-diastolic dimension of both groups returned to normal and there was no difference in closure rate, adverse events, and complications between groups. Conclusions Transcatheter device closure and surgical repair are effective interventions with excellent midterm results for treating pmVSD in children. Transcatheter device closure has a lower incidence of myocardial injury, less blood transfused, faster recovery, shorter hospital stay, and lower medical expenses. (Transcatheter Closure Versus Surgery of Perimembranous Ventricular Septal Defects; NCT00890799) (

The Annals of Thoracic Surgery, 2010

Background. Isolated hemodynamically significant ventricular septal defects (VSD) were previously treated surgically. Since the introduction of percutaneous (PC) devices, the management of isolated VSD has evolved. In our center, Amplatzer devices have been implanted for selected isolated perimembranous VSD since 2002.