Doubly Committed and Juxtaarterial Ventricular Septal Defect: Outcomes of the Aortic and Pulmonary Valves

Early experience with transcatheter ventricular septal defects closure with the KONAR-MF multifunctional occluder

Introduction

Transcatheter device closure of ventricular septal defects (VSDs) offers an appealing and effective alternative to surgical repair. The Lifetech™ Konar-Multifunctional Occluder (MFO) VSD occluder has gained increasing application due to its versatility and promising outcomes.

Objectives

We aim to evaluate our experience with the MFO device for VSD closure.

Methods

We conducted a prospective analysis of clinical data from 151 patients who underwent percutaneous closure of muscular and perimembranous VSDs using the MFO device at our institution between November 2018 and September 2023. Comprehensive assessments of safety and procedural outcomes were performed.

Results

The patient's mean age was 55.4 ± 51.6 months (range, 6 months to 31 years), and the mean weight was 17.6 ± 11.9 kg (range, 5-86). Among the patients, 94 (62.3%) had perimembranous defects, while the remaining had muscular VSDs. The mean defect diameter was 4.8 ± 1.5 mm (range, 2-10). The retrograde approach was applied in 133 patients (88.7%). Device implantation was successful in 98.7% of patients. One procedure (0.7%) failed due to device migration, requiring surgical retrieval and VSD closure, and another patient with a significant residual shunt needed placement of an additional device in another session. The mean procedure time was 44 ± 2 min, with a mean fluoroscopy time of 12.8 ± 7.7 min. The mean follow-up duration was 11 ± 9.7 months (range, 6-35). Non-significant shunts were found in 32 patients (21.2%). Newly acquired valve regurgitation was observed in 16 patients (10.6%), including 11 patients (7.3%) with trivial-to-mild aortic regurgitation and 5 (3.3%) with moderate-to-severe tricuspid regurgitation. Electrophysiological adverse events occurred in 5 patients (3.3%), including nodal rhythm (n = 3, 2%), intermittent heart block (n = 1, 0.7%), and severe bradycardia (n = 1, 0.7%). Vascular complications were documented in 13 patients (8.6%) including one developing chronic vascular occlusion.

Conclusion

Percutaneous VSD closure with the MFO device is a safe, effective, and feasible procedure via both antegrade and retrograde approaches.

Multimodal Imaging Diagnosis of Doubly Committed Juxta-Arterial Ventricular Septal Defect and Persistent Left Cranial Vena Cava in a Goat

•Multimodal imaging contributes to understanding of caprine congenital heart disease. •Echocardiography is useful for identification of DCJA VSD. •3D heart models aid in assessing vascular anomalies not noted on echocardiography.

Double outlet right ventricle

This review article addresses the history, morphology, anatomy, medical management, and different surgical options for patients with double outlet right ventricle.

Outlet Ventricular Septal Defect: Impact of Surgery on the Late Aortic and Pulmonary Valve Functions

This study retrospectively evaluated long-term post-operative aortic and pulmonary valve functions in outlet ventricular septal defects. We evaluated aortic regurgitation and pulmonary regurgitation using pre- and post-operative echocardiograms. Overall, 158 patients who underwent intracardiac repair due to outlet ventricular septal defects with aortic valve deformity or congestive heart failure were included. The median follow-up period was 7 years (interquartile range: 0-17 years), without deaths or pacemaker implantations. The age, weight, ventricular septal defect size, and mild aortic regurgitation at surgery were factors associated with post-operative residual aortic regurgitation. Mild pulmonary regurgitation was observed in 12%, 30%, and 40% of patients 5, 10, and 15 years after surgery, respectively. There were no significant differences in age and weight at which surgery was performed between patients with mild pulmonary regurgitation and those with less than mild pulmonary regurgitation. However, the number of sutures across the pulmonary valve was associated with post-operative pulmonary regurgitation (P < 0.01). As some patients with mild pre-operative aortic regurgitation may not improve even after surgery, early surgical intervention is necessary when aortic regurgitation appears. Some patients may develop post-operative pulmonary regurgitation in the long term, suggesting the need for careful follow-up.

Early Ventricular Septal Defect Closure Prevents the Progression of Aortic Regurgitation: A Long-Term Follow-Up Study

According to current short-term evidence, ventricular septal defect (VSD) closure should be performed as early as possible after aortic regurgitation (AR) diagnosis in pediatric patients to prevent AR progression. However, long-term follow-up data are lacking. Therefore, our aim was to evaluate the long-term follow-up (≥ 10 years) of patients who underwent VSD closure as early as possible after AR diagnosis and to evaluate whether early VSD closure prevents progression of AR. This was a retrospective cohort study of 42 patients with VSD and AR who had undergone VSD closure at a median age of 2.9 years, with a median waiting period from AR diagnosis to VSD closure of 3.4 months and follow-up of a median 13.1 years (interquartile range 10.0-15.8 years). The preoperative degree of AR was trivial in 25 patients, mild in 15, and moderate in 2. Of the 33 patients followed up for ≥ 10 years, none required aortic valve replacement and there was no incidence of mortality. The degree of AR improved or did not change, except in 1 patient. The size of the VSD (odds ratio [OR] 0.85; 95% confidence interval [CI] 0.62-1.18; p = 0.33), time from diagnosis to surgery (OR 1.00; 95% CI 1.000-1.001; p = 0.657), and age at the time of surgery (OR 1.00; 95% CI 0.998-1.004; p = 0.452) were not predictive of persistent postoperative AR. Therefore, VSD closure performed as early as possible after AR diagnosis could successfully prevent AR progression in patients with less than moderate preoperative AR, eliminating the need for aortic valve replacement and valvuloplasty.

Imaging the adult with simple shunt lesions: position paper from the EACVI and the ESC WG on ACHD. Endorsed by AEPC (Association for European Paediatric and Congenital Cardiology)

In 2018, the position paper 'Imaging the adult with congenital heart disease: a multimodality imaging approach' was published. The paper highlights, in the first part, the different imaging modalities applied in adult congenital heart disease patients. In the second part, these modalities are discussed more detailed for moderate to complex anatomical defects. Because of the length of the paper, simple lesions were not touched on. However, imaging modalities to use for simple shunt lesions are still poorly known. One is looking for structured recommendations on which they can rely when dealing with an (undiscovered) shunt lesion. This information is lacking for the initial diagnostic process, during repair and at follow-up. Therefore, this paper will focus on atrial septal defect, ventricular septal defect, and persistent arterial duct. Pre-, intra-, and post-procedural imaging techniques will be systematically discussed. This position paper will offer algorithms that might help at a glance. The document is prepared for general cardiologists, trainees, medical students, imagers/technicians to select the most appropriate imaging modality and to detect the requested information for each specific lesion. It might serve as reference to which researchers could refer when setting up a (imaging) study.

Tetralogy of Fallot: morphological variations and implications for surgical repair

OBJECTIVES

Tetralogy of Fallot is characterized by anterocephalad deviation of the outlet septum, along with abnormal septoparietal trabeculations, which lead to subpulmonary infundibular stenosis. Archives of retained hearts are an important resource for improving our understanding of congenital heart defects and their morphological variability. This study aims to define variations in aortic override, coronary arterial patterns and ventricular septal defects in tetralogy of Fallot as observed in a morphological archive, highlighting implications for surgical management.

METHODS

The Birmingham Children's Hospital archive contains 211 hearts with tetralogy of Fallot, of which 164 were analysed [69 (42.1%) unrepaired and 95 (57.9%) operated specimens]. A detailed morphological and geometric analysis was performed using a rigorous 5-layer review process.

RESULTS

Anomalies were observed in the orifices, origins and course of the coronary arteries: 20 hearts (13.0%) had more than 2 orifices and 3 hearts (1.9%) had a single orifice. In 7 hearts (4.3%), a coronary artery crossed the right ventricular outflow tract. The extent of aortic override ranged from 31.0% to 100% (median of 59.5%). The ventricular septal defect was most often perimembranous (139, 84.8%), but we also found muscular (14, 8.5%), atrioventricular (7, 4.3%) and doubly committed juxta-arterial (2, 1.2%) variants.

CONCLUSIONS

Anatomical variations are common and can impact surgical management. Anomalous coronary arteries may require a conduit rather than a transannular patch. Variability in aortic override determines the size of patch used to baffle blood to the aorta. The type of ventricular septal defect affects patch closure and the risk of postoperative conduction defects.

Long-term outcomes after conventional surgical repair versus perventricular device occlusion for doubly committed subarterial ventricular septal defects: a propensity score matched study

OBJECTIVES

This study aimed to investigate the long-term outcomes of perventricular device occlusion and surgical repair for doubly committed subarterial ventricular septal defect using propensity score matched analysis because previous comparative studies were limited by differences in the baseline characteristics.

METHODS

We reviewed inpatients with isolated doubly committed subarterial ventricular septal defect aged <18 years who underwent surgical repair or device occlusion between January 2011 and December 2017. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics.

RESULTS

A total of 336 patients underwent surgical repair; 99 underwent device occlusion. After matching, the repair group included 164 patients, whereas the device group had 91 patients. There were no significant differences in the baseline characteristics. The median follow-up periods were 46 and 58 months for the device and repair groups, respectively. No significant difference was noted in the rates of cumulative adverse events in the 2 groups (7.9% vs 5.5%; P = 0.61). The repair group required longer periods of hospitalization (P = 0.002) and mechanical ventilation (P = 0.016). No grade 3 or higher valvular regurgitation or high-degree atrioventricular block events were observed. All patients were in sinus rhythm at the last follow-up examination.

CONCLUSIONS

In selected patients with doubly committed subarterial ventricular septal defect, compared with conventional repair, perventricular device occlusion has comparable efficacy and safety, less invasiveness in terms of time in the hospital and on mechanical ventilation and avoidance of cardiopulmonary bypass.

Outcomes of closure of doubly committed subarterial ventricular septal defects in adults

BACKGROUND

Outcome data of doubly committed subarterial ventricular septal defect closure in adults are limited.

METHODS

A review was made of the inpatients >18 years of age who underwent doubly committed subarterial ventricular septal defect closure between June 2010 and June 2017.

RESULTS

The patients were categorised into two groups: The valve intervention group consisted of 31 patients who underwent aortic valvuloplasty, aortic valve replacement, or repair of sinus Valsalva aneurysm in addition to doubly committed subarterial ventricular septal defect closure; non-valvular intervention group comprised 58 patients who underwent only doubly committed subarterial ventricular septal defect closure. The groups did not differ by sex and age. Patients in the valve intervention group, with a larger ventricular septal defect size, were shorter and tended to be lighter. The valve intervention group had more patients with pneumonia perioperatively. No infective endocarditis and reoperation were noted during the study period. At last follow-up, 91 and 96.6% of the studied patients were free from left ventricle dilation and pulmonary hypertension. In patients without pre-operative aortic regurgitation, 12 developed new mild aortic regurgitation during the follow-up.

CONCLUSIONS

About 34.8% of adult patients with doubly committed subarterial ventricular septal defect required concurrent intervention on aortic valve or sinus Valsalva aneurysm. The midterm results of doubly committed subarterial ventricular septal defect closure in adult patients were favourable. However, the incidence of new mild aortic regurgitation after ventricular septal defect closure was high (27.3%). Long-term follow-up of aortic regurgitation progression is needed.

Left thorax approach to repair doubly committed juxta-arterial ventricular septal defect with Da Vinci robotic system

Robotic repair of the ventricular septal defect was performed mainly for perimembranous type via right thorax approach. Minimally invasive strategies for doubly committed juxta-arterial ventricular septal defect were limited. Here, for the first time, we successfully repaired a doubly committed juxta-arterial ventricular septal defect with Da Vinci robotic system via left thorax approach. The technique could provide excellent exposure of surgical field and accurate repair, with the advantage of reducing trauma and shortening the overall length of stay.

Progression of Aortic Regurgitation After Subarterial Ventricular Septal Defect Repair: Optimal Timing of the Operation

In patients with subarterial ventricular septal defect (VSD), the progression of aortic regurgitation (AR) still remains unclear. This review is to identify the incidence of AR progression after VSD repair and to determine the optimal operation timing for subarterial VSD repair with or without aortic valve prolapse or AR. From January 2002 to December 2015, 103 patients who underwent subarterial VSD repair alone at our hospital were reviewed. All patients routinely underwent echocardiography (echo) performed by our pediatric cardiologists. The operative approach was through the pulmonary artery in all patients. The median age of patients at operation was 10 months (range 3 to 16.5 months). Eighty-nine patients (86.4%) underwent subarterial VSD closure before the age of 4 years. In the preoperative evaluation, 27.2% (28 patients) of the patients showed more than faint degree AR. The mean follow-up duration after VSD repair was 6.6 ± 4.0 years. In the latest follow-up echo after VSD repair, four patients had more than mild degree AR owing to aortic valve abnormalities or delayed operation period. Among them, AR progression occurred in only one patient (0.98%). Early and accurate assessment of the anatomical morphology of the aortic valve and optimal operation timing may be important to achieve better outcomes after repair and to prevent the development of aortic valve complications.

Doubly committed Subarterial Ventricular Septal defect repair: An experience of 51 cases

Objective:

To review the surgical outcome of doubly committed subarterial (DCSA) ventricular septal defect repair.

Method:

Data of 51 patients of doubly committed sub arterial Ventricular septal defect from January 2012 to June 2017 that were referred to Chaudhary Pervaiz Elahi institute of Cardiology Multan was retrospectively reviewed using electronic database. All patients were operated by first author. In our study, we segregated patients into four main groups depending on presence or absence of aortic structural defect and degree of aortic valve regurgitation. Group-A comprised of nineteen (37%) patients who neither had aortic structural nor functional abnormality while Group-B had six (11.7%) patients, having aortic valve cusp prolapse without aortic regurgitation. Group-C and Group-D consists of seventeen (33.3%) and nine (17.6%) patients respectively depending upon degree of aortic regurgitation. Furthermore, six (11.7%) patients among these 51 had associated defects as well.

Results:

Group-A patients had no aortic valve regurgitation post operatively and at follow up of 22.6 months (1.8 years) as well. In Group-B, aortic valve was not addressed and aortic regurgitation was also not present post operatively or on follow up of 33.6 months (2.8 years). Similarly, in Group-C aortic valve was not addressed, these patients also did not show progression of disease on regular follow up of 18 months (1.5 year). While, in Group-D, eight patients underwent aortic valve repair and one patient had aortic valve replacement. Aortic regurgitation improved significantly in all patients of this group and remained unchanged on follow up of 22.7 months (1.8 years).

Conclusion:

Early closure of doubly committed subarterial ventricular septal defect with appropriate management of aortic valve disease can halt the process of disease progression.

Aortic valve prolapse misdiagnosed as aortic sinus aneurysm in patients with ventricular septal defect. Analysis of the echocardiographic findings

Objectives:

To retrospectively analyzed the preoperative echocardiographic findings of 9 patients with doubly committed ventricular septal defect (VSD) associated with aortic valve prolapse and to summarize the reasons for misdiagnosis.

Methods:

This retrospective study was conducted in Yijishan Hospital, Wannan, Anhui, China between June 2005 and May 2015. Using transthoracic echocardiography (TTE), 92 patients were diagnosed with doubly committed VSD associated with rupture of an aortic sinus aneurysm. The operative findings proved to be in accordance with the echocardiographic findings in 83 patients. Nine patients were confirmed as showing doubly committed VSD associated with perforation of a prolapsed aortic valve. We primarily discussed the 9 patients who were misdiagnosed by TTE.

Results:

Aneurysm-like protrusions could be detected by 2-dimensional TTE in the right ventricular outflow tract (RVOT) in 9 patients. All of the aneurysm-like protrusions were confirmed by surgery as over-enlarged right coronary leaflets bulging into the RVOT.

Conclusion:

Occasionally, in patients with doubly committed VSD, aortic valve prolapse can be misdiagnosed as an aortic sinus aneurysm. To reduce the misdiagnosis rate and to provide a more precise preoperative diagnosis, multi-section, and multi-angle observation of these diseases should be performed.

Transthoracic Device Closure of Juxtaarterial Ventricular Septal Defects: Midterm Follow-Up Results

BACKGROUND

In recent years, minimally invasive transthoracic device closure has been introduced as an alternative treatment option for selected patients with juxtaarterial ventricular septal defects. This study evaluated the midterm safety and efficacy of using device closure in selected patients.

METHODS

Between January 2008 and December 2014, 25 patients with juxtaarterial ventricular septal defects who met the inclusion criteria were enrolled in this study. Periventricular closure was attempted using minimally invasive transthoracic device closure without cardiopulmonary bypass under general anesthesia and transesophageal echocardiography guidance. Patients were strictly monitored according to a standard protocol by one specially appointed doctor.

RESULTS

Minimally invasive transthoracic device closure was successfully performed in 23 patients (92%) with a median age of 18 months. Device closure failed in 2 patients (1 with aortic regurgitation and 1 with right ventricular outflow tract stenosis), and they were converted to an open operation. No severe complications (device shift, significant arrhythmia, ventricular outflow tract obstruction, or obvious valve regurgitation) were observed. There was no closure-associated valve regurgitation. No patient had worrisome progression of aortic regurgitation or pulmonary regurgitation.

CONCLUSIONS

In select patients, minimally invasive transthoracic device closure of juxtaarterial ventricular septal defects appears to be safe and effective, with good midterm outcomes.

Shunt Lesions Part I: Patent Ductus Arteriosus, Atrial Septal Defect, Ventricular Septal Defect, and Atrioventricular Septal Defect

OBJECTIVES

This review summarizes the current understanding of the pathophysiology and perioperative management of patent ductus arteriosus, atrial septal defect, ventricular septal defect, and atrioventricular septal defect.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSIONS

The four congenital cardiac lesions that are the subject of this review, patent ductus arteriosus, atrial septal defect, ventricular septal defect, and atrioventricular septal defect, are the most commonly found defects causing a left-to-right shunt. These defects frequently warrant transcatheter or surgical intervention. Although the perioperative care is relatively straightforward for many of these patients, there are a number of management strategies and complications associated with each intervention. The treatment outcomes for all of these lesions are very good in the current era.

Surgery for doubly committed ventricular septal defects

OBJECTIVES

Doubly committed ventricular septal defects (VSDs) account for up to almost one-third of isolated ventricular septal defects in Asian countries, compared with only 1/20th in western populations. In our surgical experience, this type of defect accounted for almost three-quarters of our practice. To date, patch closure has been considered the gold standard for surgical treatment of these lesions. Our objectives are to evaluate the indications and examine the outcomes of surgery for doubly committed VSDs.

METHODS

Between October 2013, when our service of paediatric cardiac surgery was opened, and December 2014, 24 patients were referred for surgical closure of VSDs. Among them, 17 patients (71%), with the median age of 6 years, ranging from 2 to 9 years, and with a median body weight of 19 kg, ranging from 11 to 56 kg, underwent surgical repair for doubly committed defects. In terms of size, the defect was considered moderate in 4 and large in 13. Aortic valvular regurgitation (AoVR) was present in 11 patients (65%) preoperatively, with associated malformations found in 14 (82%), with 5 patients (29%) having two or more associated defects.

RESULTS

After surgery, there was trivial residual shunting in 2 patients (12%). AoVR persisted in 6 (35%), reducing to trivial in 5 (29%) and mild in 1 (6%). Mean stays in the intensive care unit and hospital were 2.6 ± 1.2 days, ranging from 2 to 7 days, and 6.8 ± 0.8 days, ranging from 6 to 9 days, respectively. The mean follow-up was 14 ± 4 months, ranging from 6 to 20 months, with no early or late deaths and without clinical deterioration.

CONCLUSIONS

The incidence of doubly committed lesions is high in our experience, frequently associated with AoVR and other associated malformation. Early detection is crucial to prevent further progression of the disease. Patch closure remains the gold standard in management, not least since it allows simultaneous repair of associated intracardiac defects.