TRANSCATHETER CLOSURE OF VSD: WHAT CAN BE SAFELY DONE?

Jonas D. Del Rosario, MD, FPCCClinical Associate ProfessorUP College of Medicine

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First DO NO HARM

Objectives

What types of VSD are amenable for catheter closure at this time

How to select and screen patients who are amenable for catheter closure of VSD

Concerns/Complications Present our limited experience with the

use of VSD coil in the Philippines

Ventricular Septal Defect

Most common congenital cardiac malformation

Surgery is the standard method for closure of VSD Mortality rate in high volume centers is less

than 0.6% to 1.8% Complication < 1% Complete heart block is less than 1%

VSD Closure with PFM VSD Coils

Transcatheter closure of VSD (TCCVSD)

Remains to be the most challenging interventional procedure in CHD

Various devices have been used with a high degree of effectiveness to primarily close muscular and perimembranous VSD

Advantages of TCC of VSD

Avoids median sternotomy scar Avoids cardiopulmonary bypass Shorter hospital stay Shorter recovery period

Indication for Closure of VSD

Hemodynamically significant Qp:Qs > 1.5

LA or LV enlargement Cardiomegaly on CXR Failure to Thrive Previous episode of Infective

Endocarditis

Soft Indications for VSDDeveloped since catheter closure

Better psychosocial impact on patient

Avoid the inherent problems related to stigma of having a heart defect

Employability Health Insurance Heavy vehicle license Sports participation (as a

professional)

Concerns/Complications Complexity of procedure Steep Learning Curve Applicability in selected group Proximity of aortic and tricuspid valve Conduction system (arrhythmias, heart block) Residual shunt with risk of infective endocarditis Mechanical haemolysis Embolization

Proper selection of patients is the KEY.

What Is Not Amenable For TCC

AV Canal Type (Inlet)

Large Perimembranous VSD(Unrestrictive)

Subpulmonic VSD

Multiple (Swiss Cheese) VSDs

VSD as a component of a more complex lesion

Amplatzer Muscular VSD occluder

Muscular VSD Device

Anterior Muscular VSD device

Amplatzer PM VSD Occluder (AVSO)

First device specifically designed for membranous VSD

First reported by Hijazi et al 2002 and Thanopoulos in 2003

Perimembranous VSD device

Amplatzer PM VSD occluder (AVSO)

Became the most popular device to close VSDs worldwide with good short and medium term outcome

Occurrence of complete heart block in an unpredictable manner even after years post-implantation has currently tempered the enthusiasm of the interventional community (Incidence 1-5%)

Heart Block of AVSO

Rim of the VSD closed by AVSO remains under continuous pressure due to the stenting philosophy of this device

This can cause trauma to the neighboring conduction system

What Type of Can Be Safely Occluded

Muscular VSDMidmuscular/Apical

Perimembranous VSDRestrictiveVentricular Septal AneurysmVSD rim > 3mm from aortic ValveDefect is <6mm from RV sidePresents like a “FUNNEL”

The PFM VSD Coil

• Novel attachment mechanism • Stiff distal loops, covered with polyester filaments

5.5F delivery catheter; Distal Coil Diameter: 8,10,12,14 mm

Nit Occlud Lê VSD – Deutsche Studie4 Zentren 35 Fälle

eine Heilbehandlung (Köln)

VenezuelaDr. Borges

12 Patienten

BrasilienDr. Pedra

Dr. ChamieDr. SimoesDr. Rossi

28 Patienten

VietnamDr. TrieuDr. NhanDr. HuanDr. HieuDr. Binh

35 Patienten

ThailandDr. Kritvikrom 14 Patienten

MalaysiaDr. Wong

Dr. Samion6 Patienten

ArgentinienDr. GranjaDr. Peirone4 Patienten

Saudi ArabienDr. GalalDr. Ekram

9 Patienten

ÄgyptenDr. Sayhed3 Patienten

VSD Coil (Nit-Occlud Le VSD Coil)

Conical-shaped nitinol coil More flexible, softer and conforms to the

shape of VSD Less traumatic

Used for: Perimembranous VSD with aneurysmal

pouch and muscular VSD Muscular VSD

Shapes of membranous and muscular VSD

Courtesy Dr. L. Simoes

VSD with VSA formation

VSD with VSA formation

Occlusion of VSD using the PFM VSD Coil

117 Patients with restrictive VSDPerim. VSD (n=97) Musc. VSD (n=10) Subpulm. VSD (n=10)

International Experience with the PFM VSD Coil

International Experience with the PFM VSD Coil

International Experience with the PFM VSD Coil

International Experience with the PFM VSD Coil

International Experience with the PFM VSD Coil

Device Displacement: noneDevice Fracture: noneDevice Embolization: 2 (transcath. removal within 3 hours)

AI: n = 2 (I-II°)TR: n = 2 (II°)

Hemolysis: n = 5 4 transient 1 severe, device surgically removed

Problems of conduction system: none!

Occlusion of VSD using the PFM VSD Coil

Coil SelectionDistal coil diameter is• at least double the minimal diameter (right ventricular opening) • equal or 1-2mm larger than left ventricular diameter of VSD.

Distal Loop Diameter: 8 mm10 mm12 mm14 mm

Prox. Loop Diameter: 6 mm6 mm6 mm8 mm

VSD Coil (UP-PGH) experience 5 patients 3y – 29 y VSD with Ventricular septal

aneurysm 1st case was done 3 years ago Last 4 cases done 1 year ago Total occlusion after 1 month No incidence of heart block, CVA, IE

and death

The implantation procedure

Guidance by TOE or TTETransvenous implantation

PDA device to close VSDs?

Perimembranous VSD which are “conical” (like a PDA type A)

Distance from the aortic valve is >4mm Amplatz Duct Occluder

Nguyen Lan Hieu, MD, PhD Hanoi Medical University-Vietnam Heart

Institute Performed in some patients in Heart Center

Pm VSD (conical)

VSD (conical)

Summary

TCC of VSD is a complex interventional procedure that can be performed effectively and safely in well selected patients

Muscular VSDs can still be closed by Amplatzer devices

VSD coils are safe in aneurysmatic OR conical perimembranous VSDs and muscular VSD which have a distance from the AV node

Majority of the perimembranous VSDs should be closed by surgery at this time until a better device can be made that will not produce heart block at a higher rate

Long-term follow-up is important

Thank you for your attention