Outcomes of a modified approach to transcatheter closure of perimembranous ventricular septal defects

Percutaneous Transcatheter Closure of Congenital Ventricular Septal Defects

Ventricular septal defects (VSDs) are the most common kind of congenital heart disease and, if indicated, surgical closure has been accepted as a gold-standard treatment. However, as less-invasive methods are preferred, percutaneous device closure has been developed. After the first VSD closure was performed percutaneously by Lock in 1988, both techniques and devices have developed consistently. A perventricular approach for closure of muscular VSD in small patients and the closure of perimembranous VSD using off-label devices are key remarkable developments. Even though the Amplatzer membranous VSD occluder (Abbott) could not be approved for use due to the high complete atrioventricular conduction block rate, other new devices have shown good results for closure of perimembranous VSDs. However, the transcatheter technique is slightly complicated to perform, and concerns about conduction problems after VSD closure with devices remain. There have been a few reports demonstrating successful closure of subarterial-type VSDs with Amplatzer devices, but long-term issues involving aortic valve damage have not been explored yet. In conclusion, transcatheter VSD closure should be accepted as being as effective and safe as surgery but should only be performed by experienced persons and in specialized institutes because the procedure is complex and requires different techniques. To avoid serious complications, identifying appropriate patient candidates for device closure before the procedure is very important.

Transcatheter Closure of Atrial and Ventricular Septal Defects: JACC Focus Seminar

The field of congenital interventional cardiology has experienced tremendous growth in recent years. Beginning with the development of early devices for transcatheter closure of septal defects in the 1970s and 1980s, such technologies have evolved to become a mainstay of treatment for many atrial septal defects (ASDs) and ventricular septal defects (VSDs). Percutaneous device closure is now the preferred approach for the majority of secundum ASDs. It is also a viable treatment option for selected VSDs, though limitations still exist. In this review, the authors describe the current state of transcatheter closure of ASDs and VSDs in children and adults, including patient selection, procedural approach, and outcomes. Potential areas for future evolution and innovation are also discussed.

Influence of percutaneous catheter intervention for congenital perimembranous ventricular septal defects in children on the cardiac conduction system and associated risk factors: a meta-analysis

Background

The aim of this study was to investigate adverse outcomes and risk factors for the cardiac conduction system in children with perimembranous ventricular septal defects (pmVSDs) who had been treated by catheter intervention.

Method

PubMed, EMBASE, Web of Science, and the Cochrane Library were searched for studies in English on interventional treatment of pmVSDs in pediatric patients published up to the end of October 15, 2020. We used random- or fixed-effect models to obtain pooled estimates of the success rate and postoperative complications.

Results

A total of 1650 pediatric patients from 8 publications were included, with a mean age ranging from 3.44 to 8.67 years old. The pooled estimate of successful implantation was 98.2% (95% CI 97.1–99.4%, I² = 69.4%; P < 0.001), and the incidence of cardiac conduction system complications was 17.4% (95% CI 8.4–26.4%, I² = 96.1%; P < 0.001), among which the incidence of heart block was 14.8% (95% CI 6.4–23.3%, I² = 96.9%; P = 0.001). The incidence of impulse formation disorders was 4.1% (95% CI 0.7–7.6%, I² = 91.7%; P = 0.019), and the incidence of complete atrioventricular block was 0.8% (95% CI 0.3–13%, I² = 0.0%; P = 0.001). Risk factors for newly emerging arrhythmias included the VSD size MD = 0.89 (95% CI 0.46–1.32, I² = 0%; P < 0.0001) and device size MD = 1.26 (95% CI 0.78–1.73, I² = 0%; P < 0.00001).

Conclusions

Percutaneous catheter intervention is safe and effective in treating pediatric patients with pmVSD, and the risk factors leading to arrhythmias include the sizes of the pmVSD and device.

Minimally-invasive-perventricular-device-occlusion versus surgical-closure for treating perimembranous-ventricular-septal-defect: 3-year outcomes of a multicenter randomized clinical trial

Background

Minimally-invasive-perventricular-device-occlusion (MIPDO) combined superiority of surgical-repair and percutaneous-device-closure in treating perimembranous-ventricular-septal-defect (pmVSD). This study was to evaluate the efficacy and safety of MIPDO for treating pmVSD, comparing with surgical-repair.

Methods

Patients aged ≥3 months with isolated pmVSDs were randomized to undergo either surgical or MIPDO procedure, with the median follow-up time of 49 months. The primary outcome was the rate of complete pmVSD closure at discharge. The secondary outcomes included the adverse events during hospitalization and follow-up, chest tube output volume, blood transfusion volume, procedural duration, ventilation time, hospitalization duration and hospitalization cost. Also, perioperative cardiac performance and systemic conditions were evaluated.

Results

Of the 313 patients (9 months to 42 years old; median, 4 years old) with pmVSDs recruited from 3 centers, 100 were finally enrolled and randomly allocated 1:1 into two groups. The non-inferiority (non-inferiority margin -8.0%) of MIPDO to surgical closure regarding efficacy was shown in both intention-to-treat (0, 95% CI: -0.055 to 0.055) and per-protocol populations (0.02, 95% CI: -0.018 to 0.058). Although the rate of adverse events was similar between groups, the MIPDO group showed superiority in procedural duration, ventilation time, chest tube output volume, postoperative hospitalization time and hospitalization cost compared with surgical group (P<0.05). Moreover, MIPDO method showed comparable perioperative cardiac performance with milder change of systemic condition.

Conclusions

In patients with pmVSDs, MIPDO method showed non-inferiority to surgical closure in efficacy for both intention-to-treat and per-protocol population with easier perioperative recovery, economic benefit and promising outcomes.

Beyond atrial septal defect closure, it is time to start seriously considering closing ventricular septal defects with devices

PURPOSE OF REVIEW

The purpose of this review is to discuss the history and current state of transcutaneous device closure of ventricular septal defects.

RECENT FINDINGS

Newer devices and techniques have expanded the role of transcutaneous device closure of ventricular septal defects. Device closure of ventricular septal defects is a mainstay of therapy in many parts of the world. Device closure in smaller infants has relatively higher risks than larger infants and older children. The potential for the development of complete heart block remains a concern with this procedure.

SUMMARY

Transcutaneous device closure of ventricular septal defects is a safe alternative to surgical repair in many patients.

Ventricular Septal Defect Closure Devices, Techniques, and Outcomes

Transcatheter closure of ventricular septal defects (VSDs) was first documented in 1988. The early studies of VSD closure were successful but there were high complication rates, particularly early and late-onset complete heart block. However, the development and use of new vascular occlusion devices in an off-label fashion has improved the range of patients who can be treated and reduced the complication rates. In particular, the rate of complete heart block documented in contemporary studies of VSD closure has fallen to levels at or below those documented in the surgical VSD closure literature.

Postprocedural Outcomes and Risk Factors for Arrhythmias Following Transcatheter Closure of Congenital Perimembranous Ventricular Septal Defect: A Single-center Retrospective Study

BACKGROUND

Currently, transcatheter closure of perimembranous ventricular septal defect (pmVSD) is a widely accepted therapeutic modality. However, arrhythmias, especially postprocedural heart blocks, are a concern and outcomes are not very clear. This study explored the outcomes and risk factors of arrhythmias associated with transcatheter device closure of pmVSD.

METHODS

A total of 395 patients diagnosed with pmVSD who successfully underwent transcatheter intervention between January 2010 and December 2015 in our center were retrospectively reviewed. Electrocardiographic data before and after the procedure were collected and analyzed. We first evaluated the potential risk factors including gender, age, weight, inlet and outlet diameters of defect, subaortic rim length, occluder size, corrected occluder size into body surface area, fluoroscopy time, presence of aneurysm, and deployment position. We compared the potential risk factors between arrhythmia and nonarrhythmia groups using univariate analysis, followed by logistic analysis for independent risk factors.

RESULTS

Various arrhythmias were detected in 95 cases (24.1%) following transcatheter closure procedure. Logistic regression analysis revealed that eccentric (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.2-7.2) and large occluders (OR 2.0, 95% CI: 1.6-2.5), as well as long fluoroscopy time (OR 1.1, 95% CI: 1.1-1.2), were correlated with postprocedural arrhythmia. During 35.5 months (range: 9-80 months) of follow-up, most of the patients (74 out of 95) reverted to normal heart rhythm.

CONCLUSIONS

The mid-term outcome of patients with arrhythmias after transcatheter closure of pmVSD was satisfactory as most of the patients recovered normal rhythm. Eccentric, large device and long fluoroscopy time increase the risk of arrhythmias after transcatheter closure of pmVSD.