Ventricular Septal Defects

Cardiac Conduction Disorders Due to Acquired or Genetic Causes in Young Adults: A Review of the Current Literature

Cardiac conduction disorders can manifest in young adults in isolated forms, associated with myocardial diseases or as part of a multiorgan disorder. Underlying causes of cardiac conduction disorders may be genetically determined or acquired. Cardiac conduction disorder in young adults is a complex and often underestimated and underrecognized disease that may need of a multidisciplinary team for the diagnosis, treatment, and long-term management of these patients. Therefore, it is crucial to raise clinicians' awareness of this condition. In this review, we provide a comprehensive update on the cause, diagnosis, and treatment of young adults with cardiac conduction disorders, also suggesting potential strategies to improve the current clinical management of these patients.

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 Management of Complex Congenital Heart Disease: A Case of Atrial and Ventricular Septal Defects With a Bifid Apex

Congenital heart disease (CHD) is one of the most common congenital anomalies influenced by both genetic and environmental factors. Atrial septal defect (ASD) and ventricular septal defect (VSD) are among the most common types of CHD. ASD is more common in females and often remains asymptomatic during childhood, leading to delayed diagnosis. Both surgical and percutaneous closure techniques are used, with evidence supporting early intervention for improved outcomes. This study presents the case of a female patient with CHD, including ASD, VSD, and a bifid left ventricular apex, who was treated with both surgical and percutaneous approaches. The patient underwent open heart surgery for ASD closure at the age of 17 years. Eight years later, residual ASD and VSD were identified, and percutaneous transcatheter closure was performed using closure devices. Post-procedural imaging confirmed successful defect closure, a significant reduction in left-to-right shunting, and a decrease in right ventricular pressure. However, residual mitral valve prolapse and moderate mitral regurgitation persisted, requiring ongoing monitoring. The presence of a bifid apex in this patient adds a unique anatomic consideration to managing CHD. While typically considered a benign variant, its association with other structural abnormalities requires careful evaluation. Future management strategies should include detailed imaging studies, such as cardiac MRI, to assess long-term ventricular function and detect potential complications. This case highlights the importance of a comprehensive, multimodal management strategy that includes surgical and transcatheter techniques for complex coronary artery disease cases. Regular follow-up with echocardiography and cardiac MRI is essential to monitor residual defects, assess ventricular function, and ensure long-term treatment success. Early detection and timely intervention are critical to optimizing patient outcomes, preventing complications, and improving quality of life.

Fate of Residual Patch Leak After Surgical Closure of Congenital Perimembranous Ventricular Septal Defects

IntroductionVentricular septal defects (VSDs) account for 50% of congenital heart defects in children. Surgical closure of moderate to large VSDs using patch material is considered the standard treatment in children to prevent future complications.ObjectivesWe evaluated the fate of VSD patch leak and its impact on aortic and tricuspid valve regurgitation at one year after surgery.MethodsThis retrospective study consisted of patients with a perimembranous VSD who underwent surgery between January 2016 and July 2021. Demographic, echocardiographic, clinical, and operative data were retrospectively reviewed. All patients' echocardiographic images were analyzed at discharge, 6, and 12 months after surgery. Echocardiography assessment focused on the degree of residual VSD (rVSD) patch leak and aortic and tricuspid regurgitation grade compared with preoperative echocardiography.ResultsSeventy-one consecutive patients who underwent perimembranous VSD surgical closure were reviewed. No patient required reintervention. There was one early mortality during follow-up. Of the 70 patients with complete follow-up, 24 patients (34.33%) had a 1-2 mm rVSD patch leak and 4 patients (5.7%) had a 2-3 mm rVSD patch leak at the time of discharge. At 12-month follow-up echocardiography, 67 patients (95.7%) had no rVSD patch leak. Aortic and tricuspid valve regurgitation significantly improved from discharge to 12 months after surgery. The size of the patch leak did not affect patients' weight gain (P ≥ .05).ConclusionsWe demonstrated that a 2 mm or less rVSD patch leak is benign, has no impact on tricuspid or aortic valve function, no impact on weight gain, and almost always decreases in severity or disappears.

Rapid left ventricular dimension normalization following transcatheter ventricular septal defect closure in children

Background

This study evaluated left ventricular (LV) dimension changes after transcatheter ventricular septal defect (VSD) closure in children and identified factors influencing these changes.

Methods

We retrospectively studied 124 children (mean age: 3.5 ± 3.0 years) with preoperative LV Z-scores ≥2 who underwent successful transcatheter VSD closure. LV end-diastolic diameter (LVEDD) Z-scores were assessed using echocardiography at 1, 3, 6, and 12 months postoperatively. Predictors of LV dimension normalization were identified using binary logistic regression.

Results

The mean VSD size was 5.7 ± 2.0 mm. LVEDD Z-scores significantly decreased over time, with 87.1 % of patients achieving normalization at 1 month. The most rapid change occurred in the first postoperative month (64 % decrease). Age showed an inverse association (OR 0.41, p = 0.036) and VSD size a positive association (OR 1.53, p = 0.007) with LVEDD Z-score normalization at 1 month. Device-specific complications, including conduction disturbances, occurred more frequently with non-symmetric occluders (13.0 %) than with perimembranous symmetric occluders (3.0 %) (p = 0.077). Although complications delayed recovery, normalization was achieved by 12 months in nearly all cases.

Conclusions

Transcatheter VSD closure results in rapid normalization of LV dimensions in children, with the most significant changes occurring in the first postoperative month. The identified associations of age and VSD size with LV dimension improvement support transcatheter VSD closure as an effective treatment for hemodynamically significant VSDs in children.

Recurrent endocarditis on restrictive perimembranous septal defect causing aortic insufficiency

Infective endocarditis (IE) in children is a rare entity which presents a high rate of events during follow-up. Congenital heart disease, i particular ventricular septal defect (VSD), is the main predisposing condition to IE at those ages. The long-term risk of IE is of concern and whose follow-up can be complicated by a relapse of IE and reintervention. The endocarditis can affect the aortic valve (AV) and induce destructive lesions such as perforation of the valve making it leaky. We report an uncommon case of recurrent endocarditis on restrictive perimembranous VSD, and onset of severe aortic regurgitation after surgical closure, requiring a reoperation.

Predictive Scoring System for Spontaneous Closure of Infant Ventricular Septal Defect: The P-VSD Score

Ventricular septal defect (VSD) is a common congenital heart disease. However, consensus on the utility of echocardiography in predicting spontaneous closure (SC) of VSD remains lacking. This study aimed to identify and validate significant predictors of SC through a predictive scoring system. This retrospective study included medical records of 712 echocardiography instances performed on 304 patients diagnosed with VSD from 2016 to 2020 in their first year of life. A novel scoring system for predicting the SC of VSD was developed and validated using another dataset from different hospitals. Of the 304 patients, 215 (70.7%) had perimembranous (PM) VSDs and 89 had muscular (29.3%) VSDs. The median follow-up periods were 36.2 (interquartile range [IQR], 13-59) months and 13.7 9 (IQR, 5-37.4) days for PM and muscular VSDs, respectively. The overall SC rate during follow-up was 29.3%. Pulmonary hypertension (HTN), concomitant left ventricle (LV)-right atrium (RA) shunt, VSD size to aortic valve (AV) annulus size ratio, and left ventricular end-diastolic dimension (LVEDD) z-score were significant risk factors affecting SC of VSD. The "P-VSD" score, a new scoring system, demonstrated an area under the curve for predictability of 0.769. Pulmonary HTN, concomitant LV-RA shunt, LVEDD z-score, and VSD size-to-AV annulus size ratio at diagnosis were significantly associated with non-SC VSD after infancy. The P-VSD score can predict the SC of VSD in clinical settings and simplify the identification and appropriate management of high-risk patients.

The molecular mechanisms of cardiac development and related diseases

Cardiac development is a complex and intricate process involving numerous molecular signals and pathways. Researchers have explored cardiac development through a long journey, starting with early studies observing morphological changes and progressing to the exploration of molecular mechanisms using various molecular biology methods. Currently, advancements in stem cell technology and sequencing technology, such as the generation of human pluripotent stem cells and cardiac organoids, multi-omics sequencing, and artificial intelligence (AI) technology, have enabled researchers to understand the molecular mechanisms of cardiac development better. Many molecular signals regulate cardiac development, including various growth and transcription factors and signaling pathways, such as WNT signaling, retinoic acid signaling, and Notch signaling pathways. In addition, cilia, the extracellular matrix, epigenetic modifications, and hypoxia conditions also play important roles in cardiac development. These factors play crucial roles at one or even multiple stages of cardiac development. Recent studies have also identified roles for autophagy, metabolic transition, and macrophages in cardiac development. Deficiencies or abnormal expression of these factors can lead to various types of cardiac development abnormalities. Nowadays, congenital heart disease (CHD) management requires lifelong care, primarily involving surgical and pharmacological treatments. Advances in surgical techniques and the development of clinical genetic testing have enabled earlier diagnosis and treatment of CHD. However, these technologies still have significant limitations. The development of new technologies, such as sequencing and AI technologies, will help us better understand the molecular mechanisms of cardiac development and promote earlier prevention and treatment of CHD in the future.

Cardiac arrhythmia in individuals with steroid sulfatase deficiency (X-linked ichthyosis): candidate anatomical and biochemical pathways

Circulating steroids, including sex hormones, can affect cardiac development and function. In mammals, steroid sulfatase (STS) is the enzyme solely responsible for cleaving sulfate groups from various steroid molecules, thereby altering their activity and water solubility. Recent studies have indicated that Xp22.31 genetic deletions encompassing STS (associated with the rare dermatological condition X-linked ichthyosis), and common variants within the STS gene, are associated with a markedly elevated risk of cardiac arrhythmias, notably atrial fibrillation/flutter. Here, we consider emerging basic science and clinical findings which implicate structural heart abnormalities (notably septal defects) as a mediator of this heightened risk, and propose candidate cellular and biochemical mechanisms. Finally, we consider how the biological link between STS activity and heart structure/function might be investigated further and the clinical implications of work in this area.

Elevated microRNA-187 causes cardiac endothelial dysplasia to promote congenital heart disease through inhibition of NIPBL

Cardiac endothelial cells are essential for heart development, and disruption of this process can lead to congenital heart disease (CHD). However, how microRNAs influence cardiac endothelial cells in CHD remains unclear. This study identified elevated microRNA-187 (miR-187) expression in embryonic heart endothelial cells from CHD fetuses. Using a conditional knockin model, we showed that increased miR-187 levels in embryonic endothelial cells induce CHD in homozygous fetal mice, closely mirroring human CHD. Mechanistically, miR-187 targets NIPBL, which is responsible for recruiting the cohesin complex and facilitating chromatin accessibility. Consequently, the endothelial cell-specific upregulation of miR-187 inhibited NIPBL, leading to reduced chromatin accessibility and impaired gene expression, which hindered endothelial cell development and ultimately caused heart septal defects and reduced heart size both in vitro and in vivo. Importantly, exogenous miR-187 expression in human cardiac organoids mimicked developmental defects in the cardiac endothelial cells, and this was reversible by NIPBL replenishment. Our findings establish the miR-187/NIPBL axis as a potent regulator that inhibits cardiac endothelial cell development by attenuating the transcription of numerous endothelial genes, with our mouse and human cardiac organoid models effectively replicating severe defects from minor perturbations. This discovery suggests that targeting the miR-187/NIPBL pathway could offer a promising therapeutic approach for CHD.

Assessment of 4D flow MRI for quantification of left-to-right shunt in pediatric patients with ventricular septal defect: comparison with right heart catheterization

Objectives

The percentage of shunt fraction significantly impacts the management of patients with congenital shunts, influencing strategic choices such as surgical or interventional procedures. This study compared the estimated shunt fraction (the ratio of pulmonary-to-systemic flow, Qp/Qs) for quantifying the left-to-right shunt in children with ventricular septal defect (VSD) using heart catheterization, four-dimensional (4D) flow, and two-dimensional (2D) flow magnetic resonance imaging (MRI). The goal was to establish a non-invasive and reliable measurement ratio between pulmonary and systemic blood flow in these patients.

Methods

Between July 2022 and June 2023, patients scheduled to undergo invasive right heart catheterization were included in this study. MRI was performed one hour before the catheterization procedure. The correlation of shunt fraction was assessed between all methods after calculating the Qp/Qs ratio from 2D and 4D flow MRI and catheterization.

Results

A total of 24 patients (aged 3-15 years, eight females) were ultimately included in the study. The Qp/Qs ratios obtained from 4D flow had a robust correlation (correlation coefficient r = 0.962) compared to those obtained during catheterization. Cardiac catheterization recorded the mean shunt fraction at 1.499 ± 0.396, while 4D flow measured it at 1.403 ± 0.344, with no significant difference between the two techniques. Moreover, there was a reasonable correlation (r = 0.894) between 2D flow measurements of Qp/Qs and the results obtained from catheterization, with a mean shunt fraction of 1.326 ± 0.283.

Conclusion

4D flow MRI has the potential to be a non-invasive method for accurately measuring the left-to-right shunt in children with VSD.

Ventricular septal defect complicating acute myocardial infarction: diagnosis and management. A Clinical Consensus Statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the ESC Working Group on Cardiovascular Surgery

Ventricular septal defects are a rare complication after acute myocardial infarction with a mortality close to 100% if left untreated. However, even surgical or interventional closure is associated with a very high mortality and currently no randomized controlled trials are available addressing the optimal treatment strategy of this disease. This state-of-the-art review and clinical consensus statement will outline the diagnosis, hemodynamic consequences and treatment strategies of ventricular septal defects complicating acute myocardial infarction with a focus on current available evidence and a focus on major research questions to fill the gap in evidence.

Intra-Hisian Wenckebach after surgical closure of conoventricular ventricular septal defect

We report a 5-year-old girl with transient complete atrioventricular (AV) block following surgical closure of a symptomatic conoventricular ventricular septal defect (VSD) which recovered on post-operative day 9. She later presented with exertional dizziness and fatigue. While congenital cardiac defect repairs are occasionally complicated by complete heart block, this patient was found to have intra-Hisian Wenckebach which is rare in the pediatric population and can be very difficult to discern from surface electrocardiograms and by Holter monitoring. Mechanisms of post-surgical AV block, including intra-Hisian Wenckebach, are not well characterized in the pediatric population.

Patients with a Bicuspid Aortic Valve (BAV) Diagnosed with ECG-Gated Cardiac Multislice Computed Tomography-Analysis of the Reasons for Referral, Classification of Morphological Phenotypes, Co-Occurring Cardiovascular Abnormalities, and Coronary Artery Stenosis

Background/Objectives: The aim of this study was to analyze a group of patients with a bicuspid aortic valve (BAV) examined with ECG-gated cardiac CT (ECG-CT), focusing on the assessment of the clinical reasons for cardiac CT, cardiovascular abnormalities coexisting with their BAV, and coronary artery stenosis. Methods: A detailed statistical analysis was conducted on 700 patients with a BAV from a group of 15,670 patients examined with ECG-CT. Results: The incidence of a BAV in ECG-CT was 4.6%. The most common reason for examination was suspicion of coronary heart disease-31.1%. Cardiovascular defects most frequently associated with a BAV were a VSD (4.3%) and coarctation of the aorta (3.6%), while among coronary anomalies, they were high-take-off coronary arteries (6.4%) and paracommissural orifice of coronary arteries (4.4%). The analysis of the coronary artery calcium index showed significantly lower values for type 2 BAV compared to other valve types (p < 0.001), with the lowest average age in this group of patients. Moreover, the presence of a raphe between the coronary and non-coronary cusps was associated with a higher rate of significant coronary stenosis compared to other types of BAVs (p < 0.001). Conclusions: The most common reason for referral for cardiac ECG-CT in the group ≤ 40-year-olds with a BAV was the suspicion of congenital cardiovascular defects, while in the group of over 40-year-olds, it was the suspicion of coronary artery disease. The incidence of cardiovascular abnormalities co-occurring with BAV and diagnosed with ECG-CT differs among specific patient subgroups. The presence of a raphe between the coronary and non-coronary cusps appears to be a potential risk factor for significant coronary stenosis in patients with BAVs.

The Prevalence and Spontaneous Closure of Ventricular Septal Defects the First Year of Life

INTRODUCTION

Ventricular septal defect (VSD) is one of the most common congenital heart defects. We aimed to determine the prevalence of VSD in a population-based cohort of newborns and assess the rate of spontaneous closure during the first 12 months of life.

METHODS

The Copenhagen Baby Heart Study (CBHS) is a population-based cohort study, including more than 25,000 newborns born in the greater Copenhagen area. Newborns underwent echocardiography within 60 days of birth. Newborns with VSDs had echocardiographic follow-up after 3, 6, and 12 months.

RESULTS

A total of 850 newborns (3.3% of 25.556) with a VSD were identified in the CBHS. Of these, 787 (92.6% [95% CI 90.1-94.2]) were muscular VSDs, 60 (7.0% [95% CI, 5.5-9.0]) were perimembranous, and 3 (0.4% [95% CI, 0.0-1.1]) were subarterial. After 1 year, 83.5% (607 of 727) of all VSDs had closed spontaneously, resulting in a decrease of prevalence from 3.3% at birth to 0.5% in 1-year old children. Muscular VSDs showed significantly higher rate of spontaneous closure compared with perimembranous VSDs (86.9% (582/670) vs. 46.9% (25/54), p < 0.001). Determinants associated with spontaneous closure were smaller size of the VSD (p < 0.001) and the absence of multiple VSDs (p < 0.0025).

CONCLUSION

The prevalence of VSDs in unselected newborns was 3.3%. Almost 9/10 of all VSDs identified in newborns, close spontaneously during the first year of life, ultimately resulting in a prevalence of VSD in 1-year-old children of 0.5%. The identified factors associated with spontaneous closure were muscular type, small size, and absence of multiple VSDs.

Severe Pulmonary Hypertension From Combined Ventricular Septal Defect and Rheumatic MIitral Valve Disease: A Case Report and Literature Review

Most individuals with ventricular septal defect survive to adulthood which allows time for other complications such as pulmonary arterial hypertension to gradually develop over a period of time. When there are other associated cardiac conditions that also contribute to the development of pulmonary hypertension such as valvular heart disease, the pulmonary hypertension may be exaggerated. Because these different etiologies of the pulmonary hypertension have different mechanisms, their coexistence can complicate patient management. We present a 26-year-old man with a large ventricular septal defect and rheumatic mitral valve disease who developed severe pulmonary hypertension that became complicated by atrial fibrillation and later sudden cardiac death.

A Thrombus within an Interventricular Membranous Septal Aneurysm Leading to Cerebral Infarction: A Case Report

Interventricular membranous septal aneurysms are rare. Since these aneurysms can lead to complications such as obstruction of right ventricular outflow and thromboembolism, the detection of this aneurysm has clinical significance. Herein, we report a case of an interventricular membranous septal aneurysm with an internal thrombus thought to be the cause of a cerebral infarction.

Human Genetics of Congenital Heart Defects

Congenital heart diseases (or congenital heart defects/disorders; CHDs) are structural abnormalities of the heart and/or great vessels that are present at birth. CHDs include an extensive range of defects that may be minor and require no intervention or may be life-limiting and require complex surgery shortly after birth. This chapter reviews the current knowledge on the genetic causes of CHD.

Long-Term Effects of Child Early Surgical Ventricular Septal Defect Repair on Maternal Stress

The ventricular septal defect (VSD) represents the most common congenital heart defect (CHD). The diagnosis of and cardiac surgery for their child's VSD are highly stressful experiences for parents; especially mothers, who are at risk of developing long-lasting stress-related symptoms. This study examined long-term alterations in maternal stress including self-reported psychological and biophysiological stress levels in a case-control design. We investigated 24 mothers of children with an isolated, surgically corrected VSD compared to non-affected controls. Maternal self-reports on psychopathology, everyday stress, parenting stress and hair cortisol concentrations (HCC) were measured during children's primary school age (6-9 years, t1) and early adolescence (10-14 years, t2). In maternal self-reports, psychopathology and stress symptoms in the VSD-group and controls were comparable at t1, whereas at t2, mothers in the VSD-group even showed a decrease in psychopathology. Maternal HCC levels in the VSD-group were significantly lower (hypocortisolism) than HCC levels of controls at t1. This effect was no longer observed at t2 reflecting an approximation of HCC levels in the VSD-group to controls' levels. This study highlights the potential for improved stress hormone balance and psychological well-being in mothers following their child's surgical VSD repair. However, the need for parent-centered interventions is discussed, particularly during peri-operative phases and in early child developmental stages.

Ventricular septal defect associated with aortic regurgitation and ascending aortic aneurysm: a case report

INTRODUCTION

Ventricular septal defect (VSD) is one of the most common congenital cardiac anomalies. Patients with perimembranous VSD may have aortic regurgitation (AR) secondary to prolapse of the aortic cusp.

CASE PRESENTATION

We present a case of 23-year-old White man with VSD, AR and ascending aortic aneurysm. The patient presented to outpatient clinic with weakness and gradual worsening shortness of breath for the past 5 years. Clinical examination revealed regular heart rhythm and loud continuous systolic-diastolic murmur (Lewin's grade 6/6), heard all over the precordium, associated with a palpable thrill. The ECG showed right axis deviation, fractionated QRS in V1 and signs of biventricular hypertrophy. The chest X-ray showed cardiomegaly. Transthoracic and transesophageal echocardiograms showed a perimembranous VSD with moderate restrictive shunt (Qp/Qs = 1.6), aortic regurgitation (AR), and ascending aortic aneurysm. Other clinical and laboratory findings were within normal limits.

CONCLUSIONS

Perimembranous VSD, may be associated with aortic regurgitation and ascending aortic aneurysm as secondary phenomenon if it is not early diagnosed and successfully treated.

Cor triatriatum sinister with dextrocardia in association with ostium secundum atrial septal defect, subpulmonary ventricular septal defect and bicuspid pulmonary valve in a pig

Necropsy of a 52-day-old Camborough pig revealed numerous cardiac malformations. The positional relationship of the atria, ventricles and great vessels was a mirror image type (I, L and L): inverted arrangement of the atria, with a left-sided right atrium and right-sided left atrium (situs inversus); inverted arrangement of the ventricles, with a left-sided morphological right ventricle and right-sided morphological left ventricle (L-loop); and aortic valve to the front left relative to the pulmonary valve (L-malposed). The major malformations included an ostium secundum atrial septal defect, cor triatriatum sinister (CTS), a subpulmonary ventricular septal defect and a bicuspid pulmonary valve. Histological examination revealed myocyte hypertrophy, focal myocardial necrosis and calcification in the left morphological right ventricle of the heart. To the best of our knowledge, this is the first report of CTS in pigs. Although the individual malformations found in the present case are not unique, an unusual combination of these cardiac malformations has not been described in animals.

Three-dimensional transoesophageal echocardiography: how to use and when to use-a clinical consensus statement from the European Association of Cardiovascular Imaging of the European Society of Cardiology

Three-dimensional transoesophageal echocardiography (3D TOE) has been rapidly developed in the last 15 years. Currently, 3D TOE is particularly useful as an additional imaging modality for the cardiac echocardiographers in the echo-lab, for cardiac interventionalists as a tool to guide complex catheter-based procedures cardiac, for surgeons to plan surgical strategies, and for cardiac anaesthesiologists and/or cardiologists, to assess intra-operative results. The authors of this document believe that acquiring 3D data set should become a 'standard part' of the TOE examination. This document provides (i) a basic understanding of the physic of 3D TOE technology which enables the echocardiographer to obtain new skills necessary to acquire, manipulate, and interpret 3D data sets, (ii) a description of valvular pathologies, and (iii) a description of non-valvular pathologies in which 3D TOE has shown to be a diagnostic tool particularly valuable. This document has a new format: instead of figures randomly positioned through the text, it has been organized in tables which include figures. We believe that this arrangement makes easier the lecture by clinical cardiologists and practising echocardiographers.

Case report: Imaging features of aorta-right atrial tunnel in a dog using two-dimensional echocardiography and computed tomography

A 7-year-old castrated male Pomeranian dog weighing 5 kg presented with a right-sided continuous murmur without any clinical signs. Thoracic radiographs indicated cardiomegaly and right atrial (RA) bulging. Echocardiography revealed a tunnel originating from the right coronary sinus of Valsalva and terminating in the RA. Contrast echocardiography revealed pulmonary arteriovenous anastomoses. Computed tomography (CT) demonstrated a tortuous shunting vessel that originated from the aorta extending in a ventral direction, ran along the right ventricular wall, and was inserted into the RA. Based on these diagnostic findings, the dog was diagnosed with the aorta-RA tunnel. At the 1-year follow-up visit without treatment, the dog showed no significant change except for mild left ventricular volume overload and mildly decreased contractility. To the best of our knowledge, this is the first case report of an aorta-RA tunnel that has been described in detail using echocardiography and CT in a dog. In conclusion, the aorta-RA tunnel should be included in the clinical differential diagnoses if a right-sided continuous murmur is heard or shunt flow originating from the aortic root is identified.

Overlapping and Distinct Features of Cardiac Pathology in Inherited Human and Murine Ether Lipid Deficiency

Inherited deficiency in ether lipids, a subgroup of glycerophospholipids with unique biochemical and biophysical properties, evokes severe symptoms in humans resulting in a multi-organ syndrome. Mouse models with defects in ether lipid biosynthesis have widely been used to understand the pathophysiology of human disease and to study the roles of ether lipids in various cell types and tissues. However, little is known about the function of these lipids in cardiac tissue. Previous studies included case reports of cardiac defects in ether-lipid-deficient patients, but a systematic analysis of the impact of ether lipid deficiency on the mammalian heart is still missing. Here, we utilize a mouse model of complete ether lipid deficiency (Gnpat KO) to accomplish this task. Similar to a subgroup of human patients with rhizomelic chondrodysplasia punctata (RCDP), a fraction of Gnpat KO fetuses present with defects in ventricular septation, presumably evoked by a developmental delay. We did not detect any signs of cardiomyopathy but identified increased left ventricular end-systolic and end-diastolic pressure in middle-aged ether-lipid-deficient mice. By comprehensive electrocardiographic characterization, we consistently found reduced ventricular conduction velocity, as indicated by a prolonged QRS complex, as well as increased QRS and QT dispersion in the Gnpat KO group. Furthermore, a shift of the Wenckebach point to longer cycle lengths indicated depressed atrioventricular nodal function. To complement our findings in mice, we analyzed medical records and performed electrocardiography in ether-lipid-deficient human patients, which, in contrast to the murine phenotype, indicated a trend towards shortened QT intervals. Taken together, our findings demonstrate that the cardiac phenotype upon ether lipid deficiency is highly heterogeneous, and although the manifestations in the mouse model only partially match the abnormalities in human patients, the results add to our understanding of the physiological role of ether lipids and emphasize their importance for proper cardiac development and function.

Molecular Genetic Study on HAND2 Gene Promoter in Ventricular Septal Defect

Ventricular septal defect (VSD), the most common type of congenital heart disease (CHD), is primarily caused by cardiac dysplasia. Heart and neural crest derivatives expressed 2 (HAND2) participates in developing the right heart. The loss of HAND2 expression in humans is closely connected with ventricular septal defects. We used a case-control study to analyze the genetic variations in the HAND2 promoter region in VSD patients and controls. Some statistical analysis methods were used to analyze the association of single nucleotide polymorphisms (SNPs) with VSD. The dual-luciferase reporter assay and electrophoretic mobility shift assay (EMSA) were used to conduct functional analysis and molecular mechanism study of genetic variations. Through sequencing, we identified nine genetic variants in patients with VSD. The SNP rs2276940 G>T and rs2276941 G>A were associated with an increased risk of VSD. The dual-luciferase reporter assay showed that SNP rs2276940 G>T and rs138531627 C>G decreased the transcriptional activity of the HAND2 promoter. Transcription factors (TFs) predicting suggested that all three SNPs may change the binding of TFs. The result of EMSA showed that rs138531627 C>G may create a new binding site for TFs while rs2276940 G>T enhanced the binding affinity for TFs. These results indicated that genetic variants of the HAND2 promoter may increase the risk of VSD, and the molecular mechanism may be the change of the binding affinity of TFs.

The Interventricular Septum: Structure, Function, Dysfunction, and Diseases

Vertebrates developed pulmonary circulation and septated the heart into venous and arterial compartments, as the adaptation from aquatic to terrestrial life requires more oxygen and energy. The interventricular septum (IVS) accommodates the ventricular portion of the conduction system and contributes to the mechanical function of both ventricles. Conditions or diseases that affect IVS structure and function (e.g., hypertrophy, defects, other) may lead to ventricular pump failure and/or ventricular arrhythmias with grave consequences. IVS structure and function can be evaluated today using current imaging techniques. Effective therapies can be provided in most cases, although definitions of underlying etiologies may not always be easy, particularly in the elderly due to overlap between genetic and acquired causes of IVS hypertrophy, the most common being IVS abnormality. In this review, state-of-the-art information regarding IVS morphology, physiology, physiopathology, and disease is presented.

Pericardial cyst in a one-year-old boy with ventricular septal defect and patent ductus arteriosus

BACKGROUND

Pericardial cysts are rare, with the most common etiology being congenital. Ventricular septal defect is the most common congenital heart disease in children. However, the combination of pericardial cyst, ventricular septal defect, and patent ductus arteriosus is extremely rare.

CASE PRESENTATION

A one-year-old boy with ventricular septal defect and patent ductus arteriosus was planned for surgical correction. Intraoperatively, we made an additional diagnosis of a large pericardial cyst; and the cyst was excised along with ventricular septal defect closure and patent ductus arteriosus ligation.

CONCLUSIONS

Pericardial cysts can sometimes be missed with transthoracic echocardiography. Excision of the cyst can safely be done during concomitant cardiac surgery.

Left ventricular assist device placement in the setting of congenital VSD

We describe the management of a 59-year-old female with an unrepaired congenital ventricular septal defect (VSD) and end stage nonischemic cardiomyopathy necessitating placement of a left ventricular assist device (LVAD) as a destination treatment. Simultaneous repair of the VSD was performed during the LVAD implantation under a beating heart. The patient remained hemodynamically stable throughout her postoperative course, without signs of hypoxia or cyanosis. Following discharge, outpatient surveillance echocardiogram demonstrated successful VSD closure and no residual shunt.

Transfemoral Occlusion of Doubly Committed Subarterial Ventricular Septal Defect Using the Amplatzer Duct Occluder-II in Children

Backgrounds

The traditional treatment of doubly committed subarterial ventricular septal defect (dcVSD) is open-heart surgery. This study aimed to evaluate the feasibility, safety, and outcome of transcatheter closure of small dcVSD using Amplatzer duct occluder-II (ADO-II) in children.

Methods

Between January 2016 and April 2021, 24 children (17 male and 7 female patients) with small dcVSD who received transfemoral closure with ADO-II were enrolled retrospectively. All of their available clinical and follow-up data were evaluated.

Results

The patients' median age was 3.2 years (1.6–12.6 years, 4.2 ± 3.1 years) and body weight was 13.3 kg (10.0–38.5 kg, 16.5 ± 7.7 kg). Left ventricular angiography showed that the median dcVSD size was 2.0 mm (1.5–3.5 mm, 2.1 ± 0.6 mm). The device was successfully implanted in 23 patients (95.8%), and one patient failed to be closed because of the underestimation of defect size due to preoperative aortic valve prolapse, with 16 patients by the antegrade approach and eight patients by retrograde approach. The diameters of the device used were 3/4, 4/4, and 5/4 mm. The median operative time was 40.0 min (20.0–75.0 min, 41.7 ± 13.7 min), and the median fluoroscopic time was 5.0 min (3.0–25.0 min, 6.8 ± 5.0 min). With a follow-up duration of 1+ to 45+ months, only 1 patient presented with new-onset mild aortic regurgitation (AR).

Conclusion

Transfemoral closure of small dcVSD with ADO-II is technically feasible and safe in the selected children. However, the development or worsening of AR requires long-term follow-up.

Transcatheter closure of ventricular septal defects in children less than 10 kg: experience from a tertiary care referral hospital in Eastern India

OBJECTIVE

To assess the feasibility of percutaneous transcatheter device closure of ventricular septal defects in children weighing less than 10 kg.

BACKGROUND

Although percutaneous transcatheter device closure of ventricular septal defect is a well-established method of treatment in older children and adolescents, there is limited data on device closure in small children weighing less than 10 kg. We present our institutional experience of transcatheter VSD closure in children weighing less than 10 kg.

METHOD

Medical records were reviewed for 16 children, who were selected for device closure of ventricular septal defects based on the inclusion criteria.

RESULTS

Out of 65 patients with a diagnosis of ventricular septal defect, 16 children less than 10 kg were attempted for percutaneous device closure. In 13 patients, the device was successfully released, and 3 patients needed surgical closure of the defect. Mean age and weight of the patients were 17.3 ± 12.7 months and 6.8 ± 3.2 kg, respectively. Mean defect size was 6 mm (range 3-10). There was no incidence of device embolisation or heart block or death. Five patients had residual left-to-right shunt immediately after the device release, which got closed by the first month's follow-up. We had one accidental perforation of right ventricular free wall at the time of crossing of the defect, which was successfully repaired surgically.

CONCLUSION

Percutaneous device closure of ventricular septal defect in small children with weight below 10 kg is feasible with good short-term outcome. Careful patient selection is essential for procedural success and to avoid complications.

Patient selection, procedural planning and interventional guidance for non-valvular structural intervention

Percutaneous non-valvular structural interventions, encompassing patent foramen ovale, atrial or ventricular septal defect closure and left atrial appendage closure, are usually performed in young and healthy patients and represent a valid alternative to pharmacological or surgical interventions. In order to minimize procedural and device related complications, a careful pre-procedural planning together with an accurate intra-procedural imaging are crucial to improve patient's outcome. In this article, we review currently available evidence on patient selection, procedural planning and interventional guidance helping physician to determine who will derive the most benefit from the procedure.

Effect of change in tidal volume on left to right shunt across ventricular septal defect in children - A pilot study

Background :

Pulmonary vascular resistance, an important determinant of shunting across ventricular septal defects (VSD), rises at both extremes of lung volume.

Aims :

We sought to determine the effect of changes in tidal volumes (VT) on pulmonary blood flow (Qp), systemic blood flow (Qs), and shunt (Qp/Qs) in children with VSD.

Setting :

Single-center teaching hospital.

Design :

Prospective observational study.

Methods :

Thirty children with a mean age of 11.8 ± 5 months undergoing surgical closure of VSD were studied. Hemodynamics and shunt-related parameters were assessed using transthoracic echocardiography measured at three different VT i.e. 10, 8, and 6-ml/kg keeping the minute ventilation constant.

Results :

Reduction in VT from 10 to 8 to 6 ml/kg led to a reduction in gradient across VSD measuring 23.5, 20 and 13 mmHg respectively (P < 0.001). Similarly, right ventricluar outflow tract (RVOT) diameter, RVOT velocity time integral, Qp (57.3 ± 18.1, 50.6 ± 16.9, 39.9 ± 14.7 mL; P < 0.001), Qs (24.1 ± 10.4, 20.0 ± 8.7, 15.3 ± 6.9 mL; P < 0.001) and peak airway pressure (17.2 ± 1.5, 15.8 ± 1.3, 14.5 ± 1.2 cmHg; P < 0.001) showed progressive decline with decreasing VT from 10 to 8 to 6 ml/kg, respectively. However, Qp/Qs (2.4 ± 0.4, 2.6 ± 0.4, 2.6 ± 0.4) demonstrated a minor increasing trend.

Conclusion :

Lower V_T reduces the gradient across VSD, the pulmonary blood flow, and the peak airway pressure. Hence, ventilation with lower V_T and higher respiratory rate maintaining adequate minute ventilation might be preferable in children with VSD. Further studies are required to confirm the findings of this pilot study.

Incidence of acquired ventricular septal defect after transcatheter aortic valve replacement: A large single center experience

OBJECTIVE

To determine the rate and clinical outcomes of post-TAVR VSD.

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a safe and established procedure for patients with severe symptomatic aortic stenosis. Ventricular septal defect (VSD) is a rare complication of TAVR. The rate of post-TAVR VSD and patient outcomes are not well known.

METHODS

A retrospective record review of VSD cases occurring after all TAVRs performed between January 2012 and September 2020 at one urban US tertiary hospital. VSD rate and early- and long-term outcomes were analyzed. Computed tomography images taken before TAVR and transthoracic echocardiograms done before and after each procedure were analyzed.

RESULTS

Of the 1908 patients who underwent TAVR in the study period, 7 patients (0.37%) had post-procedure VSD. The average patient age was 77 ± 11 years with average society of thoracic surgeons short-term risk score of 6%. All 7 implanted valves were balloon-expandable. Of the 7 TAVR procedures, 5 were performed on a native tricuspid valve, 1 was performed on a native bicuspid valve, and 1 was done as a "valve-in-valve" procedure on a prior surgical bioprosthetic valve. All VSDs were small and restrictive in nature. Right heart failure in a patient with preexisting right ventricular dysfunction occurred in 1 (13%) patient who died. The remaining 6 patients (86%) were discharged. All 6 patients (86%) were alive and stable at 1 year follow-up, reporting improvement in symptoms (NYHA class I-II), with no evidence of right ventricular dysfunction.

CONCLUSION

VSD is a rare complication of TAVR. Hemodynamic and clinical sequelae in majority of the patients in this study did not result in mortality. Proper imaging techniques and appropriate pre-procedure planning are needed to decrease the incidence of VSD formation post-TAVR.

The Long-Term Change of Arrhythmias after Transcatheter Closure of Perimembranous Ventricular Septal Defects

OBJECTIVES

To observe and analyze the long-term change of different types of arrhythmias after transcatheter closure of perimembranous ventricular septal defect (pmVSD).

METHODS

We retrospectively collected the data of patients who underwent pmVSD closure in our institution from March 2002 to December 2010.

RESULTS

One hundred thirty-nine patients met the inclusion criteria, of which 265 (25.5%) had early arrhythmia. They were classified into two categories: conduction abnormality (191/1039; 18.4%) and origin abnormality (94/1039; 9.0%), including 20 patients with both types of arrhythmias. The median follow-up time was 84.5 months, and 103 patients (103/191; 53.9%) with early conduction block got permanent arrhythmias, while only three patients (3/94; 3.2%) with early anomalous origin arrhythmias still had an abnormal electrocardiogram. Serious arrhythmias (28/1039; 2.7%), including II° atrioventricular block (AVB), III° AVB, and complete left bundle branch block (CLBBB), can appear immediately in the early postoperative period (21 patients) or in the late outset (seven patients) after several months or even years (6 months to 8.3 years). Twenty patients (20/21; 95.2%) with serious arrhythmia in the early postoperative period improved after early treatment, but six patients relapsed or worsened during follow-up. At the endpoint, severe arrhythmia persisted in 13 patients, of which four patients got permanent pacemaker implanted, and one patient with recurrent CLBBB died from heart failure.

CONCLUSIONS

The probability of delayed CAVB or bundle branch block after VSD closure is low but often occurs several years after surgery. Therefore, long-term ECG follow-up should last for several years or even decades. Serious arrhythmias that appear early after transcatheter pmVSD closure may impose a risk of recurrence although they have been cured already. Close attention should be paid to the changes of cardiac function in patients with CLBBB after VSD closure, and the severity of such arrhythmia should be taken seriously and reexamined.

Personalized Genetic Diagnosis of Congenital Heart Defects in Newborns

Congenital heart disease is a group of pathologies characterized by structural malformations of the heart or great vessels. These alterations occur during the embryonic period and are the most frequently observed severe congenital malformations, the main cause of neonatal mortality due to malformation, and the second most frequent congenital malformations overall after malformations of the central nervous system. The severity of different types of congenital heart disease varies depending on the combination of associated anatomical defects. The causes of these malformations are usually considered multifactorial, but genetic variants play a key role. Currently, use of high-throughput genetic technologies allows identification of pathogenic aneuploidies, deletions/duplications of large segments, as well as rare single nucleotide variants. The high incidence of congenital heart disease as well as the associated complications makes it necessary to establish a diagnosis as early as possible to adopt the most appropriate measures in a personalized approach. In this review, we provide an exhaustive update of the genetic bases of the most frequent congenital heart diseases as well as other syndromes associated with congenital heart defects, and how genetic data can be translated to clinical practice in a personalized approach.

Isolated Ventricular Septal Aneurysm: A Differential Diagnosis for a Right Sinus of Valsalva Aneurysm

BACKGROUND A ventricular septal aneurysm (VSA) is rare and almost always an incidental finding on cardiac imaging. It is rarely an isolated phenomenon and is more commonly associated with other forms of congenital heart disease such a ventricular septal defect (VSD). Differentiating a ventricular septal aneurysm from an aneurysm of the right sinus of Valsalva is crucial as the latter usually has a more aggressive course and may require surgical intervention. Cardiac computed tomography (cardiac CT) or cardiac magnetic resonance imaging (CMR) may help confirm the diagnosis. CASE REPORT We report a case of a 42-year-old obese Japanese man with a past medical history of hyperlipidemia who described occasional effort-related palpitations when climbing stairs over the past few months but no anginal symptoms. Echocardiogram revealed normal left ventricular systolic with a presumed right sinus of Valsalva aneurysm measuring around 1.5 cm. A coronary CTA was obtained to further delineate the aneurysm and revealed normal CT angiographic appearance of a right dominant coronary artery circulation with a small aneurysmal outpouching of the membranous ventricular septum measuring 13×17 mm without any evidence of shunting, along with focal calcification of the medial aspect of the tricuspid annulus. The right sinus of Valsalva appeared normal on coronary CTA. CONCLUSIONS Membranous ventricular septal aneurysm is a rare condition that is almost always an incidental finding on echocardiography and can be mistaken for an aneurysm of the right sinus of Valsalva. Multimodality imaging and high degree of clinical suspicion are needed to accurately diagnose a ventricular septal aneurysm and to achieve favorable outcomes. A VSA usually has a benign course and is rarely a cause of arrythmia, right ventricular outflow obstruction, or valvular insufficiency.

A comparison of the outcomes of dexmedetomidine and remifentanil with sufentanil-based general anesthesia in pediatric patients for the transthoracic device closure of ventricular septal defects

Objective

To compare the safety and efficacy of dexmedetomidine and remifentanil with sufentanil-based general anesthesia for the transthoracic device closure of ventricular septal defects (VSDs) in pediatric patients.

Methods

A retrospective analysis was performed on 60 children undergoing the transthoracic device closure of VSDs from January 2019 to June 2020. The patients were divided into two groups based on different anesthesia strategies, including 30 cases in group R (dexmedetomidine- and remifentanil-based general anesthesia) and 30 cases in group S (sufentanil-based general anesthesia).

Results

There was no significant difference in preoperative clinical information, hemodynamics before induction and after extubation, postoperative pain scores, or length of hospital stay between the two groups. However, the hemodynamic data of group R were significantly lower than those of group S at the time points of anesthesia induction, skin incision, thoracotomy, incision closure, and extubation. The amount of intravenous patient-controlled analgesia (PCA), the duration of mechanical ventilation, and the length of the intensive care unit (ICU) stay in group R were significantly less than those in group S.

Conclusion

Dexmedetomidine combined with remifentanil-based general anesthesia for the transthoracic device closure of VSDs in pediatric patients is safe and effective.

4D Flow MRI Quantification of Congenital Shunts: Comparison to Invasive Catheterization

PURPOSE

To compare invasive right heart catheterization with four-dimensional (4D) flow MRI for estimating shunt fraction in patients with intracardiac and extracardiac shunts.

MATERIALS AND METHODS

In this retrospective study, patients who underwent 4D flow MRI and invasive right heart catheterization with a shunt run between August 2015 and November 2018 were included. The primary objective was comparison of estimated shunt fraction (ratio of pulmonary-to-systemic flow, Q_p/Q_s) at 4D flow and catheterization. Secondary objectives included comparison of the right ventricular-to-left ventricular stroke volume ratio (RVSV/LVSV) to shunt fraction (for those with applicable shunts) and comparison of cardiac output between 4D flow and catheterization. Statistical analysis included Pearson correlation and Bland-Altman plots.

RESULTS

A total of 33 patients met inclusion criteria (mean age, 49 years ± 16 [standard deviation]; 24 women). 4D flow measurements of Q_p/Q_s strongly correlated with those at catheterization (r = 0.938), and there was no bias. RVSV/LVSV correlated strongly with Q_p/Q_s from 4D flow (r = 0.852) and catheterization (r = 0.842). Measurements of left ventricle (Q_s) and right ventricle (Q_P) cardiac output from 4D flow and catheterization (Fick) correlated moderately overall (r = 0.673 [Q_p] and r = 0.750 [Q_s]).

CONCLUSION

Shunt fraction measurement using 4D flow MRI compares well with that using invasive cardiac catheterization.Supplemental material is available for this article.© RSNA, 2021.

Tricuspid valve detachment for ventricular septal defect closure in infants <5 kg: should we be hesitant?

 

OBJECTIVES

We compared the clinical outcomes between tricuspid valve detachment (TVD) and non-TVD for ventricular septal defect (VSD) closure in infants <5 kg.

METHODS

From January 2004 to April 2020, 462 infants <5 kg with VSD without more complex intracardiac lesions and who had undergone VSD closure through the trans-atrial approach were enrolled. Propensity score-matching analysis was performed. Clinical outcomes were compared between the paired TVD group (group D) and paired non-TVD group (group N).

RESULTS

The median age and body weight at operation were 1.9 months [interquartile range(IQR), 1.4-2.5] and 4.2 kg (IQR, 3.7-4.6). The median follow-up duration was 83.4 months (IQR, 43.5-130.4). After matching, 44 pairs were extracted from each group. There were no significant differences in all-cause mortality (P = 0.176), reoperation (P = 0.172), postoperative morbidities, including residual VSD, aortic regurgitation, atrioventricular block and significant tricuspid regurgitation (TR) (P = 0.346) between group D and group N. However, group D showed significantly less TR progression during follow-up (P = 0.019).

CONCLUSIONS

In infants <5 kg, TVD can be a reasonable and valid option for successful VSD closure without morbidities, including TR progression if the indication exists.

Unplanned Surgery After Transcatheter Closure of Ventricular Septal Defect in Children: Causes and Risk Factors

Objectives: To evaluate the causes and risk factors of unplanned surgery after transcatheter closure of ventricular septal defect (VSD) in children. Methods: A total of 773 patients with VSD who had the devices transcatheter released between January 2013 and December 2018 in our institution were retrospectively reviewed. Univariate and multivariate analyses were used to identify the risk factors for unplanned surgery. Results: Twenty four patients (3.1%) underwent unplanned surgery after transcatheter closure of VSD. The most common cause for unplanned surgery was new-onset or worsening aortic regurgitation (14/24; 58.3%), followed by occluder migration (4/24; 16.7%), complete atrioventricular block (2/24; 8.3%), severe hemolysis (2/24; 8.3%), residual shunt (1/24; 4.2%), and occluder edge near the tricuspid valve chordae (1/24; 4.2%). Logistic regression analysis revealed that primary aortic valve prolapse (OR: 5.507, 95%CI: 1.673-18.123, P = 0.005); intracristal VSD (OR: 8.731, 95%CI: 2.274-33.527, P = 0.002); eccentric occluder (OR: 4.191, 95%CI: 1.233-14.246, P = 0.022); larger occluder size (OR: 1.645, 95%CI: 1.331-2.033, P < 0.001); and pulmonary artery systolic pressure ≥45 mmHg (OR: 4.003, 95%CI: 1.073-14.941, P = 0.039) were risk factors for unplanned surgery. Conclusions: New-onset or worsening aortic regurgitation was the primary cause for unplanned surgery after transcatheter closure of VSD in children. Primary aortic valve prolapse, intracristal VSD, eccentric occluder, larger occluder size, pulmonary artery systolic pressure ≥45 mmHg could increase the risk of unplanned surgery.

Subaortic Membrane-A Savior in Large Perimembranous Ventricular Septal Defect

Ventricular septal defects (VSD) are the most common congenital cardiac defect. Patients with large VSDs present early due to an increase in the volume load on the left ventricle and pressure load on the right ventricle. Few of them present late even without surgical intervention, due to partial restriction of perimembranous (PM) VSD, either by the septal leaflet of the tricuspid valve or by aortic valve cusp prolapse into the VSD. The authors observed a novel structure (ie, subaortic membrane in this case) restricting the large PM VSD in a 15-year-old child.

Automatic recognition of murmurs of ventricular septal defect using convolutional recurrent neural networks with temporal attentive pooling

Recognizing specific heart sound patterns is important for the diagnosis of structural heart diseases. However, the correct recognition of heart murmur depends largely on clinical experience. Accurately identifying abnormal heart sound patterns is challenging for young and inexperienced clinicians. This study is aimed at the development of a novel algorithm that can automatically recognize systolic murmurs in patients with ventricular septal defects (VSDs). Heart sounds from 51 subjects with VSDs and 25 subjects without a significant heart malformation were obtained in this study. Subsequently, the soundtracks were divided into different training and testing sets to establish the recognition system and evaluate the performance. The automatic murmur recognition system was based on a novel temporal attentive pooling-convolutional recurrent neural network (TAP-CRNN) model. On analyzing the performance using the test data that comprised 178 VSD heart sounds and 60 normal heart sounds, a sensitivity rate of 96.0% was obtained along with a specificity of 96.7%. When analyzing the heart sounds recorded in the second aortic and tricuspid areas, both the sensitivity and specificity were 100%. We demonstrated that the proposed TAP-CRNN system can accurately recognize the systolic murmurs of VSD patients, showing promising potential for the development of software for classifying the heart murmurs of several other structural heart diseases.

Detection of Early Myocardial Injury in Children with Ventricular Septal Defect Using Cardiac Troponin I and Two-Dimensional Speckle Tracking Echocardiography

Children with ventricular septal defects (VSDs) are subjected to hemodynamic overload which causes myocardial injury and subsequent heart failure. Early stages of myocardial damage cannot be detected by conventional echocardiography. Two-dimensional speckle tracking echocardiography (2D-STE) and cardiac troponin I (cTnI) have been recently introduced as more accurate tools for early assessment of cardiovascular diseases. The purpose of this study is to evaluate the role of cardiac troponin I (cTnI) and 2D-STE in the early detection of VSD-induced myocardial injury. Thirty children with VSD (symptomatic and asymptomatic) and 30 controls were assessed serologically by measuring serum cTnI and by conventional echocardiography. STE was performed to measure the averaged global peak longitudinal systolic stain [G peak SL(AVG)]. Serum cTnI levels were significantly higher in patients when compared to controls (P < 0.05) and in the symptomatic group when compared to the asymptomatic group (P < 0.05). Serum cTn I level correlated positively with the left atrial (r = 0.37, P = 0.045) and left ventricular dimensions (r = 0.46, P = 0.01) and negatively with the G peak SL(AVG) (r = -0.39, P = 0.03). There were no statistically significant differences between patients and controls or between symptomatic and asymptomatic groups with regard to the G peak SL(AVG). The peak longitudinal systolic strain (measured by 2D-STE) is not affected despite the elevation of serum cTnI. Serum cTnI is a sensitive marker for early detection of myocardial injury in VSD patients even before the development of ventricular dilatation or dysfunction.

Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots

Agitated saline contrast studies are an essential component of contemporary echocardiography. Agitated saline contrast plays a critical role in the elucidation of intracardiac versus intrapulmonary shunting and can have major therapeutic implications, particularly in light of the evolution of percutaneous treatment options for atrial septal defects or a patent foramen ovale. Despite their perceived simplicity, however, there are numerous pitfalls of these investigations that can occur during their performance and interpretation. As such, the authors review the "bubble study" in identifying intracardiac and extracardiac shunts, including the history of its development, the physics and physiology of contrast enhancement, how to optimally perform and interpret an agitated saline contrast study, and its safety in unique populations.

The Natural and Unnatural History of Ventricular Septal Defects Presenting in Infancy: An Echocardiography-Based Review

BACKGROUND

Ventricular septal defect (VSD), the most common congenital heart defect, accounts for 40% of heart malformations. Despite this prevalence, there remains no consensus on the utility of echocardiography to guide modern-era treatment. In this study, we evaluated patients with isolated VSDs to test the hypothesis that echocardiographic evidence of left ventricular (LV) volume overload and type of VSD are associated with surgical intervention and to identify useful echocardiographic indicators for management of VSDs in infants and children.

METHODS

We reviewed 350 patients with VSDs diagnosed during the first year of life. Echocardiographic measurements were made at the time of diagnosis and at the endpoint. The VSD area was calculated using inner edge to inner edge dimensions obtained from two planes and indexed to body surface area. Aortic annulus dimension, left atrium to aortic root ratio, LV end-diastolic diameter, left atrial volume, VSD velocity-time integral, ejection fraction, and pulmonary to systemic blood flow ratio (Qp:Qs) were measured using conventional methods.

RESULTS

One hundred seventy-seven muscular (50.5%) and 162 perimembranous (46%) VSDs accounted for the vast majority of defects. Only seven (4%) muscular defects required surgical closure, while 76 (47%) perimembranous defects required surgery. Indexed VSD area, VSD to aortic valve ratio, indexed left atrium volume, LV end-diastolic diameter, VSD velocity-time integral, and Qp:Qs at diagnosis were significantly different between the surgical and nonsurgical groups. Ventricular septal defect area > 50 mm²/m² at initial diagnosis was independently associated with risk for surgery (P = .0055).

CONCLUSIONS

Indexed VSD area is an echocardiographic variable that can be easily measured at diagnosis and can provide insight into the likelihood of requiring surgical intervention regardless of the type and location of the defect.

Transcatheter Device Closure of Perimembranous Ventricular Septal Defect in Pediatric Patients: Long-Term Outcomes

Aims

The aim of this study is to evaluate the safety and efficacy of transcatheter device closure of perimembranous ventricular septal defects in pediatric patients at long-term follow-up.

Materials and Methods

We prospectively studied 376 patients with perimembranous VSDs between September 2008 and December 2015 who underwent percutaneous closure at our center. Transthoracic echocardiography (TTE) and electrocardiogram were done before and after the procedure in all the patients. All patients were subjected to follow-up evaluation at 1, 3, 6, 12 months, and annually thereafter with TTE and electrocardiogram.

Results

A total of 376 patients (210 males and 166 females) underwent transcatheter closure of perimembranous VSD. Mean age of patients was 8.67 ± 3.02 (range 3-18 years) and mean weight was 21.15 ± 8.31 (range 8-65 kg). The procedure was carried out successfully in 98.93% of patients with no reported mortality. Rhythm disturbances occurred in 8.5% of patients after the procedure which included three cases of complete atrioventricular block.

Conclusion

This study shows that in experienced hands transcatheter closure of perimembrnous VSD is safe and effective at long-term follow-up. With minimal morbidity and no mortality, the transcatheter is an effective alternative to surgical closure in selected patients.