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Ventricular Septal Defects Transcatheter Closure. J.V. DeGiovanni Birmingham Children’s Hospital & University Hospital Birmingham UK Advanced Angioplasty 2007. MY CONFLICTS OF INTEREST ARE: Consultant for AGA Medical Corporation Proctor and lecturer for AGA Medical, NMT Medical, WL Gore

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ventricular septal defects transcatheter closure
Ventricular Septal DefectsTranscatheter Closure

J.V. DeGiovanni

Birmingham Children’s Hospital

&

University Hospital Birmingham

UK

Advanced Angioplasty 2007

slide2

MY CONFLICTS OF INTEREST ARE:

Consultant for AGA Medical Corporation

Proctor and lecturer for AGA Medical, NMT Medical, WL Gore

Steering Committee member for Helex (Gore), SolySafe (Carag), BioStar (NMT)

study details
Study Details
  • September 2001 – January 2007
  • Total number VSD devices : 160
  • Muscular Devices: 59
  • Perimembranous Devices: 43
  • Post-infarct: 43
  • Post-trauma: 3
  • Residual post-surgery 12
vsd types
VSD Types
  • Congenital: Perimembranous, Muscular, Gerbode, Doubly-committed
  • Acquired: Iatrogenic

Residual post-surgery

Post-trauma

Post-infarct

indications
Indications
  • Left ventricular volume overload
  • Heart failure/Cardiogenic shock
  • Aortic regurgitation
  • Haemolysis
  • History of endocarditis
  • Career reasons
  • Achieving normality (?)
technique
Technique
  • General Anaesthesia
  • Trans-oesophageal echocardiography
  • Femoral vein/femoral artery
  • Internal jugular vein/femoral artery
  • Angiography
  • +/- Balloon sizing (post-MI only)
  • Amplatzer device placement and release
  • Heparin, antibiotics, antiplatelets
  • Associated procedures (ASD, BAV, RFA, VSD coil, Pulm Valvuloplasty)
amplatzer muscular devices
Amplatzer Muscular Devices
  • Muscular Waist diameter 4 – 18 mm

Waist length 7 mm

Sheath size 6 – 8 Fr

  • Muscular PI Waist diameter 16 -24

Waist length 10 mm

Sheath size 9 – 10 Fr

Left disc rim 4 mm, right disc 3mm, size increments 2 mm

muscular vsds
Muscular VSDs
  • Inlet
  • Muscular/Apical
  • Outlet
post trauma n 3
Post-trauman = 3
  • Horse Kick, surgery, 3 devices, alive
  • Bike accident, device closure, alive
  • Car accident, device pulled through, surgery, died
slide34

Post-infarct VSDPatient Details -- ALL

  • Pt No = 38; Procedures = 43
  • Male/Female = 22/16
  • Age Range(Mean) = 52 – 81 (68.6 yrs)
  • Acute/Chronic (First device) = 29/9
  • Acute/Chronic (Second device) = 3/2
  • Mean Interval between MI and Closure 129 days
  • Ditto for second device 201 days
  • Earliest device 2 days, longest 5.3 yrs
  • Mean Follow-up 18.8 months
slide35

VSD Site

  • Apical 18
  • Anterior 6
  • Muscular 5
  • Inlet/Inferior 9
  • Septal aneurysm 6
  • Multiple 5

No of defects (No of Pts) 2(2), 3(1), 4(1)

slide36

Approach

  • FA/Jugular 30
  • FA/FV 12
  • Brachial A/Jugular 1
  • Procedure Time 55 – 300 (153) Mins
  • Fluoro Time 13.6 – 133 (39) Mins
  • Device size 8 – 24 (18.7)
planning preparation
Planning & Preparation
  • Maximize fluids and inotropes
  • IABP but shoot coronaries and consider vital stenting
  • Allow recovery from reperfusion injury
  • Early intervention is usually best
  • Minimize procedural time and trauma
  • Surgical back-up
  • Post-Op care
  • Possible hybrid in some cases
major complications
Major complications
  • Leg gangrene 1
  • Contra leg embolus 1
  • IABP sepsis 1
  • Inadequate post-op care 1
  • Device embolisation 2
  • TV damage (repaired) 1
  • No endothelialisation (surgery) 1
  • Pericardial effusion 2
  • Failure (VSD too large) 2
  • Death 12

(All=31.5%, Cardiac 26.3%, Ideal 15.7%)

conclusion
Conclusion
  • Transcatheter closure of VSDs in various locations can be safely and effectively carried out using the Amplatzer occluders
  • Results are encouraging. Muscular defects comparable to surgery; perimembranous marginally less good than surgery. Post-infarct still carry high risk but better results than surgery
  • Long term follow-up essential
  • Design changes likely to follow
  • Acknowledgment
acknowledgement
Acknowledgement
  • Been M, Clift P,Davis J, Flapan D, Gray H, Hildick Smith D, Jenkins J, Khogali S, Ludman P, Northridge D, Thorne S, Townend J, Turner M, Walker M,Wheeldon N
perimembranous n 42
Perimembranousn = 42
  • Simple
  • With aneurysm: Single exit

Multiple exits

Windsock in RVOT

  • Aortic valve prolapse
muscular device n 70
Muscular Devicen = 70
  • Congenital Muscular VSD 22
  • Congenital Perimembranous VSD 36
  • Post-surgery residual 9
  • Post-trauma 3
  • Associated procedures: P. Valvuloplasty(1), PA band dilatation (1)
perimemb musc devices
Perimemb/Musc Devices
  • Failed in 4: VSD too large (Post-trauma)

Device caused LVOTO

Post-Fallot 3rd Op. VSD too big

Transient AV block with sheath

  • No conduction problems apart from 3 with LAHB, normal PR
  • No TR, AI, clots, infection
  • Device embolisation in 2 with PMVSD.Retrieved & replaced
  • Device removed severe haemolysis + large shunt
  • Transient mild haemolysis in 2 (Resolved)
  • No deaths
  • Small residual shunt in 6
off label usage of amplatzer muscular occluder
Off Label Usage of Amplatzer Muscular Occluder
  • Membranous VSD with aneurysm
  • Huge PDAs
  • Large AV malformations
  • Paravalvar prosthetic leaks
ad