Ventricular septal defects transcatheter closure
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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


Ventricular septal defects transcatheter closure

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


Ventricular septal defects transcatheter closure

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


Ventricular septal defects transcatheter closure

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)


Ventricular septal defects transcatheter closure

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


Aortic pressure black baseline red with balloon
Aortic PressureBlack = Baseline Red = With Balloon




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