Transcript delrosario - Philippine Heart Association

TRANSCATHETER
CLOSURE OF VSD:
WHAT CAN BE SAFELY DONE?
Jonas D. Del Rosario, MD, FPCC
Clinical Associate Professor
UP College of Medicine
No disclosures
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 VSD
Developed since catheter closure
 Better psychosocial impact on patient
 Avoid the inherent problems related to
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stigma of having a heart defect
Employability
Health Insurance
Heavy vehicle license
Sports participation (as a professional)
Concerns/Complications
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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 postimplantation 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 VSD
Midmuscular/Apical
Perimembranous VSD
Restrictive
Ventricular Septal Aneurysm
VSD rim > 3mm from aortic Valve
Defect is <6mm from RV side
Presents 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
Venezuela
Dr. Borges
12 Patienten
Nit Occlud Lê VSD – Deutsche Studie
4 Zentren 35 Fälle
eine Heilbehandlung (Köln)
Brasilien
Dr. Pedra
Dr. Chamie
Dr. Simoes
Dr. Rossi
28 Patienten
Argentinien
Dr. Granja
Dr. Peirone
4 Patienten
Vietnam
Dr. Trieu
Dr. Nhan
Dr. Huan
Dr. Hieu
Dr. Binh
35 Patienten
Thailand
Dr. Kritvikrom
14 Patienten
Ägypten
Dr. Sayhed
3 Patienten
Saudi Arabien
Dr. Galal
Dr. Ekram
9 Patienten
Malaysia
Dr. Wong
Dr. Samion
6 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
International Experience with the PFM VSD Coil
117 Patients with restrictive VSD
Perim. 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
Device Displacement: none
Device Fracture: none
Device Embolization: 2 (transcath. removal within 3 hours)
AI:
TR:
n = 2 (I-II°)
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 Selection
Distal coil diameter is
• at least double the minimal diameter
(right ventricular opening)
• equal or 1-2mm larger than left ventricular
diameter of VSD.
Prox. Loop Diameter:
6 mm
6 mm
6 mm
8 mm
Distal Loop Diameter:
8 mm
10 mm
12 mm
14 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
Transvenous implantation
Guidance by TOE or TTE
PDA device to close VSDs?
 Perimembranous VSD which are “conical”
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(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
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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