Perventricular device closure of perimembranous ventricular septal defect: effectiveness of symmetric and asymmetric occluders

Comparison of perventricular and percutaneous ultrasound-guided device closure of perimembranous ventricular septal defects

Background

Ultrasound-guided percutaneous device closure of perimembranous ventricular septal defects (PmVSD) is a minimally invasive recent treatment approach. Perventricular PmVSD device closure is an emerging radiation-free intervention, yet it comes with certain limitations. No studies compared both of these treatment approaches.

Methods

We performed a retrospective institutional data comparison of percutaneous (PCP Group, n = 138) and perventricular (PVP Group, n = 67) ultrasound-guided device closure procedures in 205 patients with PmVSD between March 2017 and December 2022.

Results

Patients of the PCP and PVP groups had a median age of 4.9 years (IQR, 3.1-14.0) and 5.3 years (IQR, 3.4-13.1) respectively. The median PmVSD diameter in the PCP Group was 4.0 mm (IQR, 3.3-5.3) and 5.2 mm (IQR, 4.0-7.0) in the PVP Group (p = 0.001). There was no significant difference in success rates between the PCP and PVP Groups (intention-to-treat population, 88.4% vs. 92.5%, p = 0.36; as-treated population, 88.4% vs. 89.3%, p = 0.84). 5/8 failed percutaneous cases that were shifted to the perventricular approach were successful. Compared to the PVP Group, patients of the PCP group experienced a significant decrease in ventilation time, drainage volume, and postoperative hospital stay (p < 0.001). The median follow-up period was 24 months (IQR, 6-42) for the PCP group and 61 months (IQR, 53-65) for the PVP group. The overall severe adverse event rate was 0% in the PCP group and 3.0% in the PVP group.

Conclusions

Perventricular and percutaneous ultrasound-guided device closure of PmVSD are both effective and safe treatment options. The percutaneous approach offers less trauma and faster recovery and may be the preferred approach in selected patients.

Comparison of the clinical effect between the lower sternal incision and the left parasternal fourth intercostal incision in the transthoracic closure of ventricular septal defect

Background

To analyze the clinical effect of two different ways of minimally invasive transthoracic closure in children with ventricular septal defect (VSD).

Methods

From January 2015 to July 2019, 294 children with VSD were enrolled in the Fujian Medical University Union Hospital. Patients were divided into two groups – those who underwent VSD closure through the left sternal fourth intercostal incision (group A: n = 95) and the lower sternal incision (group B: n = 129).

Results

The operation time, bleeding volume, postoperative mechanical ventilation time, postoperative intensive care unit (ICU) monitoring time, postoperative hospitalization time and complication rate in group A were significantly lower than those in group B (P < 0.05). There was no significant difference between the two groups in the operation success rate, mechanical ventilation time and total hospitalization cost (P > 0.05).

Conclusion

The transthoracic closure of ventricular septal defect through the left sternal fourth intercostal incision is feasible, safe, cosmetic, and worth popularizing.

Hybrid Transthoracic Periventricular Device Closure of Ventricular Septal Defects: Single- Center Experience

OBJECTIVE

To evaluate the efficacy of hybrid transthoracic periventricular device closure of ventricular septal defects (VSDs) in a single center.

METHODS

All patients who underwent hybrid transthoracic periventricular device closure of VSDs between January 2018 and December 2019 were retrospectively analyzed. The preoperative, operative and postoperative findings and clinical follow-ups were reviewed.

RESULTS

A total of 59 patients underwent the procedure. Transesophageal echocardiographic guidance was used in all procedures. The procedure was successful in 57 procedures (97%). The procedures of two patients were changed to openheart surgery during the same intervention due to severe aortic insufficiency (the device was not deployed) and significant residual shunt after device deployment. One major complication (1.7%) was observed after the procedure. The patient's device was dislodged within 12 hours after the procedure, and this patient underwent device extraction and VSD patch closure due to significant residual shunt. Eight (14%) minor complications were observed after the procedure, and three of them persisted during follow-up. Three of these eight complications were incomplete right bundle branch block, one of which resolved during followup; two were mild residual shunts, one of which resolved during follow-up; two were mild new-onset tricuspid valve insufficiencies; and one was mild new-onset mitral valve insufficiency; all valvular insufficiencies were resolved during follow-up.

CONCLUSION

Hybrid transthoracic periventricular device closure of VSD seems to be a good alternative approach due to its procedural success and low risk rates. The best advantage of the procedure is the possibility of switching to open-heart surgery, if necessary.

Simultaneous transthoracic intervention for multiple cardiac defects in children

BACKGROUND

Transthoracic intervention for isolated congenital heart disease (CHD) has been well tested for its technological feasibility and is increasingly used in clinical practice. We aimed to present our experience in simultaneous transthoracic intervention for multiple cardiac lesions in a series of pediatric patients.

METHODS

Between March 2015 and December 2019, 20 patients with multiple CHD were referred to this study; mean age was 18.8±8.6 (range, 4-36) months. The transthoracic echocardiography (TTE) diagnosis was atrial septal defect (ASD) and perimembranous ventricular septal defect (pmVSD) in 7 patients, patent ductus arteriosus (PDA) and ASD in 6, pmVSD and PDA in 2, pmVSD and valvular pulmonary stenosis (PS) in 2, ASD and PS in 2, and doubly committed subarterial VSD (dcsVSD) and PS in 1 patient. These patients underwent simultaneous transthoracic interventions with transesophageal echocardiography guidance. The procedure sequence was PS→VSD→PDA→ASD. Electrocardiography and TTE were scheduled at discharge and follow-ups.

RESULTS

All patients were occluded successfully without any thoracotomy conversion. Operation time was 56-120 (mean, 75±13) minutes. A 1.5-2.0-cm median sternum incision was performed in 6 ASD&PDAs, 2 ASD&PSs, and 1 dcsVSD&PS. In 11 other patients, a 1.5-2.0-cm incision in the inferior sternum was made and the chest closed with a drain. There were no serious complications before discharge and at follow-up.

CONCLUSIONS

Simultaneous transthoracic intervention for multiple cardiac defects in children is feasible with good short-term outcomes. For different lesions, the appropriate surgical incision and operational sequence can render the intervention minimally invasive and safer.

Transcatheter Closure of Patent Ductus Arteriosus under Echocardiography Guidance: A Randomized Controlled Noninferiority Trial

Background

Percutaneous occlusion under fluoroscopy guidance has become the preferred method for the treatment of patent ductus arteriosus (PDA). To avoid radiation exposure and contrast agent use, PDA occlusion under transthoracic echocardiography (TTE) guidance was conducted.

Objectives

We assessed the hypothesis that the success rate of percutaneous PDA occlusion under TTE was noninferior to that under fluoroscopy guidance.

Methods

In this single-center trial, 100 patients were randomly assigned in a 1 : 1 ratio to the TTE group (n = 50) or to the fluoroscopy group (n = 50). The primary endpoint was the success rate of occlusion, with the noninferiority margin set at 8% for the between-group difference in intention-to-treat analysis. Secondary endpoints were hospitalization duration, cost, procedure time, and rate of adverse events including occluder migration, hemolysis, peripheral vascular complications, and residual shunt at 1-month and 12-month follow-up.

Results

Patient, defect, and device characteristics were similarly distributed between groups. The success rate of occlusion was 98% for the TTE group and 100% for the fluoroscopy group (absolute difference: -2%; 95% confidence interval: -5.9% to 1.9%). Cost and procedure duration were significantly lower in the TTE group, without adverse events in either group at a median of 12.0 months (range, 10.0-15.5 months) of follow-up.

Conclusion

Percutaneous PDA occlusion can be performed via TTE guidance safely and effectively, and the success rate of the TTE-guided procedure was noninferior to that under fluoroscopy guidance, with reduced cost and procedure time. The trial is registered with http://www.chictr.org.cn (ChiCTR-ICR-15006334).

Transthoracic closure of ventricular septal defects guided by transesophageal echocardiography

Background

This study aims to investigate the effectiveness and safety of transthoracic closure of ventricular septal defects totally guided by transesophageal echocardiography.

Methods

A total of 119 patients (62 males, 57 females; mean age 2.1±5.2 years; range, 11 months to 50 years) who underwent transthoracic closure of ventricular septal defects in our center between April 2017 and November 2018 were included. All patients were evaluated in terms of the diameter and morphological features of ventricular septal defects via transesophageal echocardiography. During the procedure, transthoracic echocardiography was used as the only guiding tool for occluder implantation.

Results

Of the patients, 116 underwent successful transthoracic device closure procedure. Two patients were switched to surgical repair due to new-onset aortic regurgitation in one patient and severe arrhythmias after device release in the other patient. One patient underwent a second operation for occluder migration during the hospital stay. In the first attempt, 106 ventricular septal defect occluders were correctly positioned. Transthoracic echocardiography revealed the insecure position or significant residual shunting in 10 patients. The original device was replaced with an asymmetric device or a more extensive occluder, and satisfactory results were finally obtained. No complications such as new-onset aortic regurgitation, residual shunt, complete heart block, or device dislodgement occurred during follow-up.

Conclusion

Transthoracic closure of ventricular septal defects under the total guidance of transthoracic echocardiography is a safe and effective method.

A meta-analysis of perventricular device closure of perimembranous ventricular septal defect

Background

To investigate the safety and efficacy of perventricular device closure of perimembranous VSD (pmVSD).

Methods

PubMed and Scopus were searched for studies in English focusing on perventricular device closure of pmVSD published up to the end of March 2019. We used a random-effects model to obtain pooled estimates of the success and complication rates.

Results

A total of 15 publications comprising 1368 patients with pmVSD were included. The median follow-up duration was 2 months to 5 years, with a mean patient age ranging from 2 months to 56 years. The pooled success rate was 0.95 (I² = 86.2%, P = 0.000). The pooled rate of postoperative residual shunting was 0.02 (95% CI: 0.01–0.03, I² = 87.3%, P < 0.001). The pooled rate of residual shunting in the follow-up period was 0.001 (95% CI:-0.001–0.002, I² = 30.5%, P = 0.126). The pooled estimated rate of severe complications was 0.074 (95% CI: 0.046–0.102, I² = 30.5%, P = 0.126). The pooled incidence of complete atrioventricular block (cAVB) was 0.002 (95% CI: 0.000–0.005, I² = 0.0%, P = 0.577).

Conclusions

Perventricular device closure may be an alternative to conventional surgical repair in selected patients with pmVSD. The success rate was stable regarding the publication year and sample size and suggested both the short learning curve of this technology and its potential for wide application. The incidence of severe arrhythmia, especially cAVB, was low. These good results may be limited by the number of enrolled patients, and a more detailed and larger sample is required for further analysis.

A Comparative Study of Perventricular and Percutaneous Device Closure Treatments for Isolated Ventricular Septal Defect: A Chinese Single-Institution Experience

OBJECTIVES

To compare the advantages and disadvantages of perventricular and percutaneous procedures for treating isolated ventricular septal defect (VSD).

METHODS

A total of 572 patients with isolated VSD were selected in our hospital between January 2015 and December 2016. The patients' median age and weight were five years (1-26 years) and 29 kg (9-55 kg), respectively. The median diameter of VSD was 6.0 mm (5-10 mm). Patients were divided into two groups. In group A, perventricular device closure was performed in 427 patients; in group B, 145 patients underwent percutaneous device closure.

RESULTS

Four hundred twelve patients in group A and 135 patients in group B underwent successful closure. The total occlusion rate was 98.5% (immediately) and 99.5% (3-month follow-up) in group A, which were not significantly different from those in group B (97.7% and 100%, respectively). Patients in group A had longer intensive care unit (ICU) stay than those in group B, but patients in group B experienced significantly longer operative times than those in group A. The follow-up period ranged from 8 months to 1.5 year (median, 1 year). During the follow-up period, late-onset complete atrioventricular block occurred in two patients. No other serious complications were noted in the remaining patients.

CONCLUSION

Both procedures are safe and effective treatments for isolated VSD. The percutaneous procedure has obvious advantages of shorter ICU stay and less trauma than the perventricular procedure. However, the perventricular procedure is simpler to execute, results in a shorter operative time, and avoids X-ray exposure.

Comparison of Fast-Track and Conventional Anesthesia for Transthoracic Closure of Ventricular Septal Defects in Pediatric Patients

BACKGROUND

To compare and analyze the safety and efficacy of fast-track and conventional anesthesia for transthoracic closure of ventricular septal defects (VSDs) in pediatric patients.

METHODS

A total of 82 pediatric patients undergoing transthoracic closure of VSDs between September and December 2017 were retrospectively analyzed. The patients were divided into two groups, including 42 patients in group F (fast-track anesthesia) and 40 patients in group C (conventional anesthesia). The perioperative clinical data of both groups were collected and statistically analyzed.

RESULTS

There were no fatal complications in both groups. No complete atrioventricular block (AVB), new aortic valve regurgitation, and device closure failure were observed. No significant difference was found in preoperative general data or intraoperative hemodynamic changes between the two groups (P >0.05). However, the mechanical ventilation time, length of postoperative intensive care unit (ICU) stay, length of hospital stay, and hospitalization expenses of group F were significantly lower than those of group C (P <0.05).

CONCLUSION

It is safe and effective to use fast-track anesthesia for transthoracic closure of VSDs in pediatric patients.

Transcatheter perimembranous ventricular septal defect closure under transthoracic echocardiographic guidance without fluoroscopy

Background

Transcatheter device closure has become an alternative therapy for ventricular septal defect (VSD). This study aimed to investigate the feasibility and safety of transcatheter perimembranous VSD (pm-VSD) closure under transthoracic echocardiography (TTE) guidance alone.

Methods

Between October 2012 and July 2016, 118 patients with pm-VSD underwent an attempt of transcatheter device closure for pm-VSD through the femoral artery under TTE guidance alone. Patients were followed-up at 1, 3, 6, and 12 months after the procedure and yearly after discharge.

Results

The mean age was 11.7±12.5 years (range, 1.0-53.0 years) and the mean body weight was 32.2±21.6 kg (range, 11.5-102.0 kg). The mean diameter of the VSD was 4.0±1.1 mm (range, 3.0-8.0 mm). Transcatheter device closure under TTE guidance alone was successful in 111 patients. The average procedural time was 44.9±7.3 minutes (range, 29.0-65.0 minutes). All 111 patients were followed-up for 3.4±2.3 years. At the last follow-up, two patients had a residual shunt smaller than 2 mm, seven patients had right bundle branch block (RBBB) including one patient with complete RBBB, six patients had mild or less tricuspid regurgitation, and two patients still had trivial aortic regurgitation including one patient that had it before the procedure. Occluder malposition, complete atrioventricular block, or other complications were not observed.

Conclusions

Transcatheter pm-VSD closure can be successfully performed under TTE guidance alone with outcomes similar to those achieved with fluoroscopic guidance in selected patients with weight more than 10 kg and VSD smaller than 8 mm. However, long-term follow-up in a large number of patients would be necessary.

Unusual Hybrid Closure of Ventricular Septal Defects

A planned combined perventricular and “open heart” surgical closure of multiple ventricular septal defects had to be modified intraoperatively due to a technical fault disabling echocardiographic guidance. Through an atriotomy, device closure of a muscular defect and patch closure of a perimembranous ventricular septal defect were performed. In unusual situations, collaboration of the surgical and interventional team is crucial.