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Perventricular Device Closure of Doubly Committed Subarterial Ventral Septal Defect Through Left Anterior Minithoracotomy on Beating Hearts
Perventricular Device Closure of Doubly Committed Subarterial Ventral Septal Defect Through Left Anterior Minithoracotomy on Beating Hearts PEDIATRIC CARDIAC
Silin Pan, MD, Quansheng Xing, MD, Qian Cao, MD, Pingshan Wang, MD, Shuhua Duan, MS, Qin Wu, MD, and Kefeng Hou, MS Heart Center, Children’s Hospital, Qingdao University, Qingdao, China
Background. Surgical repair of doubly committed subarterial ventricular septal defect (VSD) under cardiopulmonary bypass has been the gold standard with full median sternotomy, complicated by skin scarring and potential mortalities and morbidities from cardiopulmonary bypass. Perventricular device closure of muscular and then perimembranous VSD on beating heats with a small subxiphoid or inferior sternotomy has been attempted in the past few years with good results. We have tried perventricular closure of doubly committed subarterial VSD through a left anterior minithoracotomy as an alternative procedure with a modified occluder. Methods. Between January 2008 and December 2010, 6 selected patients with doubly committed subarterial VSD were recruited for modified device closure on beating hearts without cardiopulmonary bypass through left anterior minithoracotomy involving a short incision through the third intercostal space. Their ages ranged from 18 to 46 months and their body weights from 11 to 23 kg. A single per-right ventricular “U” like suture under pulmonic annulus was established, and a delivery system was introduced, aided by an 18G trocar, including a guidewire, delivery
sheath, and loading sheath. A proper device was selected according to the VSD size established by transesophageal echocardiography (TEE), and then the device was released under real-time monitoring of TEE if no residual shunt, increased aortic prolapse or regurgitation, abnormal atrioventricular valvular motion appeared. Results. In 5 of the 6 children, the device was successfully closed through a left minithoracotomy with satisfactory cosmetic effects. In the other child, the procedure was converted to conventional open-heart repair because the relatively larger occluder induced significantly increased aortic regurgitation. There was no operative or late mortality or major morbidity. All children were followed up for 10 to 21 months. No residual shunt, increased aortic prolapse or regurgitation, or serious atrioventricular block was recorded until the most recent follow-up. Conclusions. Selected doubly committed subarterial VSD can be safely closed with a proper occluder through left anterior minithoracotomy. The Cosmetic results are highly satisfactory. (Ann Thorac Surg 2012;94:2070 – 6) © 2012 by The Society of Thoracic Surgeons
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exactly close to the sternum, involving a transverse incision of about 3 cm in the third intercostal space.
oubly committed subarterial ventricular septal defect (VSD) is one type of VSD, more common in the eastern races [1, 2]. Surgical repair under cardiopulmonary bypass (CPB) has been the gold standard of doubly committed subarterial VSD with full median sternotomy, complicated by skin scarring and potential mortalities and morbidities from CPB. Perventricular device closure of muscular and then perimembranous VSD with a small subxiphoid or inferior sternotomy under transesophageal echocardiography (TEE) has been attempted in the past few years, with good results [3– 8]. Our team in the past 2 years has tried device closure of doubly committed subarterial VSD on beating hearts with a modified saddlelike device complying with the anatomic structure of these VSDs, through a left anterior minithoracotomy
Patients and Methods Informed consent forms were obtained from the parents. The study was approved by the institutional review ethics board.
Demographic Characteristics of Patients Six patients with doubly committed subarterial VSD between January 2008 and December 2010 were included in our study: 4 girls and 2 boys. They ranged from 18 to 46 months in age and from 11 to 23 kg in weight. Their demographic and clinical data are described in Table 1.
Criteria for Inclusion Accepted for publication May 16, 2012. Address correspondence to Dr Xing, 217, West Liaoyang Rd, Qingdao, China; e-mail: [email protected]
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
All of the 6 children had aortic prolapse (AP) and slight or mild regurgitation. Aortic regurgitation (AR) was graded according to the level of the narrow jet reached by 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.070
Ann Thorac Surg 2012;94:2070 – 6
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Table 1. Demographic and Clinical Data of 6 Patients
1 2 3 4 5 6
Gender
Age (mo)
Weight (kg)
VSD Size From TTE (mm)
PR
AP
AR
M F F M F F
26 18 26 46 20 29
13 11 16 23 17 17
4 3 6 4 5 3
Trivial Trivial Trivial Slight Trivial Trivial
Mild Mild Mild Mild Mild Mild
Slight Trivial Slight Slight Slight Trivial
AP ⫽ aortic prolapse; AR ⫽ aortic regurgitation; foramen ovale; PR ⫽ pulmonary regurgitation;
Other Anomalies (including AVB)
AVB ⫽ atrioventricular block; ICRBB ⫽ incomplete right bundle block; TTE ⫽ transthoracic echocardiography; VSD ⫽ ventricular septal defect.
Doppler echocardiography: trivial, for just beneath the aortic valve; slight, if confined to the left ventricular outflow tract; and slight to moderate, if the jet reached the level of the anterior mitral leaflet [9]. Patients with more than mild AR or AP, or prominent aortic valvular deformity were excluded. Patients whose prolapsed aortic valve was partly adhered with interventricular septum were excluded because the adhered semilunar valve would be deformed by the implanted occluder. No accompanying anomalies needed correction with the patient under CPB.
Delivery Set and Device The delivery set was the same as we used in perimembranous and muscular VSD closure [4 – 8], including a needle, delivery sheath, loading sheath, guidewire, and delivery cable (Fig 1). The device is partly designed like a saddle without the protruding superior rim to escape from the aortic and pulmonary valve (Fig 2), with a positioning marker in the opposite side (Lifetech Scientific Co., Ltd., Shenzhen, China). The device is available in sizes ranging from 5 to 10 mm in 1-mm increments. The connecting waist is 5 mm long, and the inferior rim of the left ventricle and right ventricle disks is only 3 mm larger than the waist.
PFO (2mm jet) ICRBB
PFO ⫽ patent
heart was exposed through a left anterior minithoracotomy with the lung lobe partly pressed. The position of the VSD was reassessed by TEE, and the whole procedure was continuously guided by TEE. The puncture site in the right ventricular outflow tract was determined by the surgeon pressing the right ventricular free wall with his finger to a position perpendicular to the VSD, usually under the pulmonic annulus. It was usually unnecessary to consider the possibility of damaging the papillary muscles and moderator band for the relatively higher puncture position than we did in the perimembranous and muscular VSDs. A U-like suture was placed at the proper site, and an 18G needle was used to puncture the right ventricle in the center of this area, with the needle directed toward the VSD. The VSD was then crossed with a 0.035-inch guidewire under TEE guidance (Fig 4), and a
Procedure With the patient under general anesthesia, a small transverse incision of about 3 cm was made in the third left intercostal space exactly close to the sternum (Fig 3). The
Fig 1. Delivery set. Left to right: delivery sheath, dilator, loading sheath, delivery cable, guidewire.
Fig 2. Saddle-like occluder complying with the anatomic structure of doubly committed subarterial ventricular septal defect.
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Patient
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PAN ET AL PERVENTRICULAR DEVICE CLOSURE OF DOUBLY COMMITTED SUBARTERIAL VSD
PEDIATRIC CARDIAC Fig 3. 3-cm transverse incision.
short delivery sheath of 7Fr or 8Fr (including a dilator inside) was introduced along the wire through the VSD into the left ventricular cavity (Fig 5). Usually the guidewire was prone going to the ascending aorta through the aortic cusp, so it was very important to adjust the wire into the LV before introducing the sheath. The dilator within the sheath was then pulled back if the delivery sheath was in the proper position. The largest diameter of the VSD was carefully evaluated from multiple views, partly depending on the short-axis and long-axis views (Fig 6A, B ). The size of the saddlelike VSD device was chosen to be 2 mm larger than the measured largest diameter of the VSD. The device was attached to the delivery cable by the screw and loaded into the loading sheath. The tip of the loading sheath was introduced Fig 4. 0.035-inch guidewire crossed ventricular septal defect shown as (A) a two dimensional image and (B) a color-dopplered image.
Ann Thorac Surg 2012;94:2070 – 6
through the hemostatic valve, and the device was advanced through the sheath into the left ventricle. The left disk was slightly pulled back against the left ventricular septal surface. The key point was that the device must be deployed with its asymmetric side toward the heart apex to escape from the semilunar valves, easy to determine from the protruding marker at the rim of the disk. After confirmation that the left disk was in the proper position, the delivery sheath was slowly pulled back while the cable was kept in its position. The waist and the right disk would expand automatically for normal plasticity. The device position and profile were then carefully assessed by TEE in multiple views (Fig 7) to ensure that there was no residual shunt, increased AR, or AP or pulmonic regurgitation. The device could be easily retrieved into the sheath and redeployed if the position or size was considered unsatisfactory. The device was released by pinning the delivery cable counterclockwise after carefully checking its position and adjacent structures by TEE. The sheath was removed, and the puncture of the right ventricle free wall was closed by securing the previously placed suture. The chest was closed in a routine fashion without drainage. The patients were given intravenous heparin, 100 IU/ kg, during the procedure, and oral aspirin, 3 to 5mg/kg was given for 3 months after the procedure. They were asked to come back to the heart clinic each month in the first 3 months and then once every 3 months. Electrocardiography, chest roentgenography, and transthoracic echocardiography were arranged each time.
Results Closure was successful in 5 of the 6 patients without major complications, such as increased AR, valvular damage or associated intense regurgitation, or severe atrioventricular block (AVB). The devices used were listed as on Table 2. The patients were extubated 1 to 4
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Fig 5. Delivery sheath introduced along the wire through the ventricular septal defect into the left ventricular cavity shown as (A) a two dimensional image and (B) a color-dopplered image.
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Fig 6. Doubly committed subarterial ventricular septal defect from (A) long-axis and (B) short-axis view with aortic prolapse.
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Fig 7. Released occluder with good position shown as (A) a two dimensional image and (B) a color-dopplered image.
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hours after the operation and discharged 3 to 5 days after the operation. Transthoracic echocardiography at discharge showed no increased AR or semilunar valvular regurgitation. In the sixth patient, conversion to surgical repair with the patient under CPB was performed, although two large occluders were tried. After cardiac arrest, the patient was found to have an 8-mm VSD accompanied by significant AP, complied with echocardiograms, and closed with an autologous pericardial patch. The relatively larger occluder influenced the integrity of the aortic valve and induced intense AR. He was discharged on day 7 after the operation and had a smooth recovery.
Follow-Up The patients were followed up for 10 to 21 months. The most recent transthoracic echocardiograms revealed no increased aortic or pulmonary regurgitation and no residual shunt or device dislocation. The enlarged left atrium and left ventricle recovered normally 3 to 6 months after operation. No major arrhythmias were
recorded. Six patients remain in sinus rhythm at the most recent follow-up.
Comment Early intervention to prevent progressive AR is frequently recommended for a doubly committed subarterial VSD to prevent aortic prolapse [10 –13], given that angiographic data have suggested that aortic cusp prolapse and AR often progress concurrently [13]. For the necessity of primary closure of these VSDs to avoid progressive aortic prolapse and associated regurgitation in early childhood, the transcatheter approach is not recommended. Surgical repair with the patient under CPB has been the conventional protocol for doubly committed subarterial VSD with full median sternotomy, and it is complicated with long scarring and inevitable CPB-associated potential mortality and morbidities, although with very low incidence. As has been reported [6 – 8], perventricular device closure of muscular and then perimembranous VSD with short sternotomy under TEE
Table 2. Operation Details of 6 Patients Patient 1 2 3 4 5 6 a
VSD Size From TTE (mm)
Waist Diameter of Device Used (mm)
Transfusion (mL)
AP
AR
4 3 7 4 5 4
6 5 9, 11 (fail) 6 7 6
0 0 260 0 0 0
⫺a ⫺ ⫺ ⫺ ⫺ ⫺
⫺ ⫺ ⫹b ⫺ ⫺ ⫺
– indicates no change compared with preimplantation of device.
b
Other anomalies (including AVB) PFO (2-mm jet) ICRBB
⫹ indicates increased degree compared with preimplantation of device.
AP ⫽ aortic prolapse; AR ⫽ aortic regurgitation; AVB ⫽ atrioventricular block; ICRBB ⫽ incomplete right bundle block; foramen ovale; TTE ⫽ transthoracic echocardiography; VSD ⫽ ventricular septal defect.
PFO ⫽ patent
PAN ET AL PERVENTRICULAR DEVICE CLOSURE OF DOUBLY COMMITTED SUBARTERIAL VSD
guidance has been attempted with good preliminary and midterm follow-up results. Especially, prospective results have been recorded in perimembranous VSD patients, such as no serious AVB or increased AR. Naturally, the third type of VSD, doubly committed subarterial VSD, was targeted. Although it could be achieved through inferior sternotomy, a longer incision was needed for doubly committed subarterial VSD. We not only abandoned CPB but completed the device closure on beating hearts through a left anterior minithoracotomy based on our experience from perventricular device closure of perimembranous VSD [6 – 8]. The advantages of using the left anterior thoracotomy include not only a short intercostal incision without sternotomy but also no chest tube drainage or potential pericardial effusion. We first selected the candidates weighing more than 10 kg for operative safety. No serious AVB occurred in the patients in our group, possibly because the position of the VSD was far away from the conductive system. With good preliminary results, we will hope to try smaller patients. Chen and colleagues [14] reported device closure of 13 doubly committed subarterial VSDs with common asymmetric VSD occluders as we used in the perimembranous VSD [6 – 8], without residual shunt, noticeable aortic regurgitation, significant arrhythmias, or thrombosis. But the predominant problem is that the right disk of the occluder would possibly influence the motion and plasticity of the pulmonic valves associated with potential valvular abnormalities. The saddlelike occluder without a superior rim escapes from the semilunar valves, which partly explains why no increased aortic or pulmonary regurgitation was found in our group. However, it was still necessary for 1 patient in this group to undergo conversion to conventional surgical repair because a relatively large occluder was needed in correspondence with its diameter, which influenced the integrity of the aortic valves and induced significantly increased AR. The relatively large diameter was the reason that led to failure of periventricular closure. Accordingly, one contraindication of this procedure is that the diameter should be restrictive, usually no larger than 8 mm, from our preliminary experience. Similarly, patients with significant AP, AR, or both should not be selected as candidates for this procedure. The key to this procedure lies in the accurate and all-round echocardiographic evaluation of VSD. The echocardiographer must measure the largest diameter from different views. No solid view is suggested. The standard short-axis view, long-axis view, or any other view is not enough. The probe should be rotated from 0° to 180° to obtain an anatomic and true impression. We evaluated our patients by slightly adjusting the probe on the basis of the standard views, to delineate the heart defect as clearly as possible. Occasionally, the implanted device protruded a bit in the left ventricular outflow tract, without turbulence from the color Doppler. That is one reason why we need more patients and long-term follow-
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up, although no hemolysis, thromboembolism, or abnormal hemodynamics in the left ventricular outflow tract was observed during short-term follow-up. The preliminary and short satisfactory results of device closure of doubly committed subarterial VSD on beating hearts through a left anterior minithoracotomy with saddlelike occluders was achieved. However, more patients and long-term follow-up data are definitely needed. That is one significant drawback of our study.
References 1. Lue HC. Is subpulmonic ventricular septal defect an oriental disease? In: Lue HC, Takao A, eds. Subpulmonic ventricular septal defect. 1st ed. Tokyo: Springer-Verlag, 1986:3– 8. 2. Anzai T, Iijima T, Yoshida I, Sakata Y, Obayashi T, Ishikawa S. The natural history and timing of radical surgical operation for subpulmonic ventricular septal defects. Jpn J Surg 1991;21:487–93. 3. Bacha EA, Cao QL, Starr JP, Waight D, Ebeid MR, Hijazi ZM. Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results. J Thorac Cardiovasc Surg 2003;126:1718 –23. 4. Li F, Chen M, Qiu Z, Lu J, Wu W. A new minimally invasive technique to occlude ventricular septal defect using an occluder device. Ann Thorac Surg 2008;85:1067–71. 5. Gan CP, An Q, Lin K, et al. Perventricular device closure of ventricular septal defects: six months results in 30 young children. Ann Thorac Surg 2008;86:142– 6. 6. Xing QS, Pan SL, Zhuang ZY, et al. Minimally invasive perventricular device closure of an isolated perimembranous ventricular septal defect with a newly designed delivery system: preliminary experience. J Thorac Cardiovasc Surg 2009;137:556 –9. 7. Xing QS, Pan SL, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass: multicenter experience and mid-term follow-up. J Thorac Cardiovasc Surg 2010;138:1409 –15. 8. Xing QS, Wu Q, Pan SL, Ren YY, Wa H. Transthoracic device closure of ventricular septal defects without cardiopulmonary bypass: experience in infants weighting less than 8 kg. Eur J Cardiothorac Surg 2011;40:591–7. 9. Tomita H, Arakaki Y, Ono Y, et al. Evolution of aortic regurgitation following simple patch closure of doubly committed subarterial ventricular septal defect. Am J Cardiol 2000;86:540 –2. 10. Tatsuno K, Konno S, Ando M, Sakakibara S. Pathogenetic mechanism of prolapsing aortic valve and aortic regurgitation associated with ventricular septal defect: anatomical, angiographic and surgical considerations. Circulation 1973; 48:1028 –37. 11. Tohyama K, Satomi G, Momma K. Aortic valve prolapse and aortic regurgitation associated with sub-pulmonic ventricular septal defect. Am J Cardiol 1997;79:1285–9. 12. Yacoub MH, Khan H, Stavri G, Shinebourne E, RadleySmith R. Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of valsalva, and ventricular septal defect. J Thorac Cardiovasc Surg 1997;113:253– 61. 13. Komai H, Naito Y, Fujiwara K, Noguchi Y, Nishimura Y, Uemura S. Surgical strategy for doubly committed subarterial ventricular septal defect with aortic cusp prolapse. Ann Thorac Surg 1997;64:1146 –9. 14. Chen Q, Chen LW, Wang QM, Cao H, Zhang GC, Chen DZ. Intraoperative device closure of doubly committed subarterial ventricular septal defects: initial experience. Ann Thorac Surg 2010;90:869 –73.
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Ann Thorac Surg 2012;94:2070 – 6
Silin Pan, MD, Quansheng Xing, MD, Qian Cao, MD, Pingshan Wang, MD, Shuhua Duan, MS, Qin Wu, MD, and Kefeng Hou, MS Heart Center, Children’s Hospital, Qingdao University, Qingdao, China
Background. Surgical repair of doubly committed subarterial ventricular septal defect (VSD) under cardiopulmonary bypass has been the gold standard with full median sternotomy, complicated by skin scarring and potential mortalities and morbidities from cardiopulmonary bypass. Perventricular device closure of muscular and then perimembranous VSD on beating heats with a small subxiphoid or inferior sternotomy has been attempted in the past few years with good results. We have tried perventricular closure of doubly committed subarterial VSD through a left anterior minithoracotomy as an alternative procedure with a modified occluder. Methods. Between January 2008 and December 2010, 6 selected patients with doubly committed subarterial VSD were recruited for modified device closure on beating hearts without cardiopulmonary bypass through left anterior minithoracotomy involving a short incision through the third intercostal space. Their ages ranged from 18 to 46 months and their body weights from 11 to 23 kg. A single per-right ventricular “U” like suture under pulmonic annulus was established, and a delivery system was introduced, aided by an 18G trocar, including a guidewire, delivery
sheath, and loading sheath. A proper device was selected according to the VSD size established by transesophageal echocardiography (TEE), and then the device was released under real-time monitoring of TEE if no residual shunt, increased aortic prolapse or regurgitation, abnormal atrioventricular valvular motion appeared. Results. In 5 of the 6 children, the device was successfully closed through a left minithoracotomy with satisfactory cosmetic effects. In the other child, the procedure was converted to conventional open-heart repair because the relatively larger occluder induced significantly increased aortic regurgitation. There was no operative or late mortality or major morbidity. All children were followed up for 10 to 21 months. No residual shunt, increased aortic prolapse or regurgitation, or serious atrioventricular block was recorded until the most recent follow-up. Conclusions. Selected doubly committed subarterial VSD can be safely closed with a proper occluder through left anterior minithoracotomy. The Cosmetic results are highly satisfactory. (Ann Thorac Surg 2012;94:2070 – 6) © 2012 by The Society of Thoracic Surgeons
D
exactly close to the sternum, involving a transverse incision of about 3 cm in the third intercostal space.
oubly committed subarterial ventricular septal defect (VSD) is one type of VSD, more common in the eastern races [1, 2]. Surgical repair under cardiopulmonary bypass (CPB) has been the gold standard of doubly committed subarterial VSD with full median sternotomy, complicated by skin scarring and potential mortalities and morbidities from CPB. Perventricular device closure of muscular and then perimembranous VSD with a small subxiphoid or inferior sternotomy under transesophageal echocardiography (TEE) has been attempted in the past few years, with good results [3– 8]. Our team in the past 2 years has tried device closure of doubly committed subarterial VSD on beating hearts with a modified saddlelike device complying with the anatomic structure of these VSDs, through a left anterior minithoracotomy
Patients and Methods Informed consent forms were obtained from the parents. The study was approved by the institutional review ethics board.
Demographic Characteristics of Patients Six patients with doubly committed subarterial VSD between January 2008 and December 2010 were included in our study: 4 girls and 2 boys. They ranged from 18 to 46 months in age and from 11 to 23 kg in weight. Their demographic and clinical data are described in Table 1.
Criteria for Inclusion Accepted for publication May 16, 2012. Address correspondence to Dr Xing, 217, West Liaoyang Rd, Qingdao, China; e-mail: [email protected]
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
All of the 6 children had aortic prolapse (AP) and slight or mild regurgitation. Aortic regurgitation (AR) was graded according to the level of the narrow jet reached by 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.070
Ann Thorac Surg 2012;94:2070 – 6
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Table 1. Demographic and Clinical Data of 6 Patients
1 2 3 4 5 6
Gender
Age (mo)
Weight (kg)
VSD Size From TTE (mm)
PR
AP
AR
M F F M F F
26 18 26 46 20 29
13 11 16 23 17 17
4 3 6 4 5 3
Trivial Trivial Trivial Slight Trivial Trivial
Mild Mild Mild Mild Mild Mild
Slight Trivial Slight Slight Slight Trivial
AP ⫽ aortic prolapse; AR ⫽ aortic regurgitation; foramen ovale; PR ⫽ pulmonary regurgitation;
Other Anomalies (including AVB)
AVB ⫽ atrioventricular block; ICRBB ⫽ incomplete right bundle block; TTE ⫽ transthoracic echocardiography; VSD ⫽ ventricular septal defect.
Doppler echocardiography: trivial, for just beneath the aortic valve; slight, if confined to the left ventricular outflow tract; and slight to moderate, if the jet reached the level of the anterior mitral leaflet [9]. Patients with more than mild AR or AP, or prominent aortic valvular deformity were excluded. Patients whose prolapsed aortic valve was partly adhered with interventricular septum were excluded because the adhered semilunar valve would be deformed by the implanted occluder. No accompanying anomalies needed correction with the patient under CPB.
Delivery Set and Device The delivery set was the same as we used in perimembranous and muscular VSD closure [4 – 8], including a needle, delivery sheath, loading sheath, guidewire, and delivery cable (Fig 1). The device is partly designed like a saddle without the protruding superior rim to escape from the aortic and pulmonary valve (Fig 2), with a positioning marker in the opposite side (Lifetech Scientific Co., Ltd., Shenzhen, China). The device is available in sizes ranging from 5 to 10 mm in 1-mm increments. The connecting waist is 5 mm long, and the inferior rim of the left ventricle and right ventricle disks is only 3 mm larger than the waist.
PFO (2mm jet) ICRBB
PFO ⫽ patent
heart was exposed through a left anterior minithoracotomy with the lung lobe partly pressed. The position of the VSD was reassessed by TEE, and the whole procedure was continuously guided by TEE. The puncture site in the right ventricular outflow tract was determined by the surgeon pressing the right ventricular free wall with his finger to a position perpendicular to the VSD, usually under the pulmonic annulus. It was usually unnecessary to consider the possibility of damaging the papillary muscles and moderator band for the relatively higher puncture position than we did in the perimembranous and muscular VSDs. A U-like suture was placed at the proper site, and an 18G needle was used to puncture the right ventricle in the center of this area, with the needle directed toward the VSD. The VSD was then crossed with a 0.035-inch guidewire under TEE guidance (Fig 4), and a
Procedure With the patient under general anesthesia, a small transverse incision of about 3 cm was made in the third left intercostal space exactly close to the sternum (Fig 3). The
Fig 1. Delivery set. Left to right: delivery sheath, dilator, loading sheath, delivery cable, guidewire.
Fig 2. Saddle-like occluder complying with the anatomic structure of doubly committed subarterial ventricular septal defect.
PEDIATRIC CARDIAC
Patient
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PAN ET AL PERVENTRICULAR DEVICE CLOSURE OF DOUBLY COMMITTED SUBARTERIAL VSD
PEDIATRIC CARDIAC Fig 3. 3-cm transverse incision.
short delivery sheath of 7Fr or 8Fr (including a dilator inside) was introduced along the wire through the VSD into the left ventricular cavity (Fig 5). Usually the guidewire was prone going to the ascending aorta through the aortic cusp, so it was very important to adjust the wire into the LV before introducing the sheath. The dilator within the sheath was then pulled back if the delivery sheath was in the proper position. The largest diameter of the VSD was carefully evaluated from multiple views, partly depending on the short-axis and long-axis views (Fig 6A, B ). The size of the saddlelike VSD device was chosen to be 2 mm larger than the measured largest diameter of the VSD. The device was attached to the delivery cable by the screw and loaded into the loading sheath. The tip of the loading sheath was introduced Fig 4. 0.035-inch guidewire crossed ventricular septal defect shown as (A) a two dimensional image and (B) a color-dopplered image.
Ann Thorac Surg 2012;94:2070 – 6
through the hemostatic valve, and the device was advanced through the sheath into the left ventricle. The left disk was slightly pulled back against the left ventricular septal surface. The key point was that the device must be deployed with its asymmetric side toward the heart apex to escape from the semilunar valves, easy to determine from the protruding marker at the rim of the disk. After confirmation that the left disk was in the proper position, the delivery sheath was slowly pulled back while the cable was kept in its position. The waist and the right disk would expand automatically for normal plasticity. The device position and profile were then carefully assessed by TEE in multiple views (Fig 7) to ensure that there was no residual shunt, increased AR, or AP or pulmonic regurgitation. The device could be easily retrieved into the sheath and redeployed if the position or size was considered unsatisfactory. The device was released by pinning the delivery cable counterclockwise after carefully checking its position and adjacent structures by TEE. The sheath was removed, and the puncture of the right ventricle free wall was closed by securing the previously placed suture. The chest was closed in a routine fashion without drainage. The patients were given intravenous heparin, 100 IU/ kg, during the procedure, and oral aspirin, 3 to 5mg/kg was given for 3 months after the procedure. They were asked to come back to the heart clinic each month in the first 3 months and then once every 3 months. Electrocardiography, chest roentgenography, and transthoracic echocardiography were arranged each time.
Results Closure was successful in 5 of the 6 patients without major complications, such as increased AR, valvular damage or associated intense regurgitation, or severe atrioventricular block (AVB). The devices used were listed as on Table 2. The patients were extubated 1 to 4
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Fig 5. Delivery sheath introduced along the wire through the ventricular septal defect into the left ventricular cavity shown as (A) a two dimensional image and (B) a color-dopplered image.
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Fig 6. Doubly committed subarterial ventricular septal defect from (A) long-axis and (B) short-axis view with aortic prolapse.
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PAN ET AL PERVENTRICULAR DEVICE CLOSURE OF DOUBLY COMMITTED SUBARTERIAL VSD
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Fig 7. Released occluder with good position shown as (A) a two dimensional image and (B) a color-dopplered image.
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hours after the operation and discharged 3 to 5 days after the operation. Transthoracic echocardiography at discharge showed no increased AR or semilunar valvular regurgitation. In the sixth patient, conversion to surgical repair with the patient under CPB was performed, although two large occluders were tried. After cardiac arrest, the patient was found to have an 8-mm VSD accompanied by significant AP, complied with echocardiograms, and closed with an autologous pericardial patch. The relatively larger occluder influenced the integrity of the aortic valve and induced intense AR. He was discharged on day 7 after the operation and had a smooth recovery.
Follow-Up The patients were followed up for 10 to 21 months. The most recent transthoracic echocardiograms revealed no increased aortic or pulmonary regurgitation and no residual shunt or device dislocation. The enlarged left atrium and left ventricle recovered normally 3 to 6 months after operation. No major arrhythmias were
recorded. Six patients remain in sinus rhythm at the most recent follow-up.
Comment Early intervention to prevent progressive AR is frequently recommended for a doubly committed subarterial VSD to prevent aortic prolapse [10 –13], given that angiographic data have suggested that aortic cusp prolapse and AR often progress concurrently [13]. For the necessity of primary closure of these VSDs to avoid progressive aortic prolapse and associated regurgitation in early childhood, the transcatheter approach is not recommended. Surgical repair with the patient under CPB has been the conventional protocol for doubly committed subarterial VSD with full median sternotomy, and it is complicated with long scarring and inevitable CPB-associated potential mortality and morbidities, although with very low incidence. As has been reported [6 – 8], perventricular device closure of muscular and then perimembranous VSD with short sternotomy under TEE
Table 2. Operation Details of 6 Patients Patient 1 2 3 4 5 6 a
VSD Size From TTE (mm)
Waist Diameter of Device Used (mm)
Transfusion (mL)
AP
AR
4 3 7 4 5 4
6 5 9, 11 (fail) 6 7 6
0 0 260 0 0 0
⫺a ⫺ ⫺ ⫺ ⫺ ⫺
⫺ ⫺ ⫹b ⫺ ⫺ ⫺
– indicates no change compared with preimplantation of device.
b
Other anomalies (including AVB) PFO (2-mm jet) ICRBB
⫹ indicates increased degree compared with preimplantation of device.
AP ⫽ aortic prolapse; AR ⫽ aortic regurgitation; AVB ⫽ atrioventricular block; ICRBB ⫽ incomplete right bundle block; foramen ovale; TTE ⫽ transthoracic echocardiography; VSD ⫽ ventricular septal defect.
PFO ⫽ patent
PAN ET AL PERVENTRICULAR DEVICE CLOSURE OF DOUBLY COMMITTED SUBARTERIAL VSD
guidance has been attempted with good preliminary and midterm follow-up results. Especially, prospective results have been recorded in perimembranous VSD patients, such as no serious AVB or increased AR. Naturally, the third type of VSD, doubly committed subarterial VSD, was targeted. Although it could be achieved through inferior sternotomy, a longer incision was needed for doubly committed subarterial VSD. We not only abandoned CPB but completed the device closure on beating hearts through a left anterior minithoracotomy based on our experience from perventricular device closure of perimembranous VSD [6 – 8]. The advantages of using the left anterior thoracotomy include not only a short intercostal incision without sternotomy but also no chest tube drainage or potential pericardial effusion. We first selected the candidates weighing more than 10 kg for operative safety. No serious AVB occurred in the patients in our group, possibly because the position of the VSD was far away from the conductive system. With good preliminary results, we will hope to try smaller patients. Chen and colleagues [14] reported device closure of 13 doubly committed subarterial VSDs with common asymmetric VSD occluders as we used in the perimembranous VSD [6 – 8], without residual shunt, noticeable aortic regurgitation, significant arrhythmias, or thrombosis. But the predominant problem is that the right disk of the occluder would possibly influence the motion and plasticity of the pulmonic valves associated with potential valvular abnormalities. The saddlelike occluder without a superior rim escapes from the semilunar valves, which partly explains why no increased aortic or pulmonary regurgitation was found in our group. However, it was still necessary for 1 patient in this group to undergo conversion to conventional surgical repair because a relatively large occluder was needed in correspondence with its diameter, which influenced the integrity of the aortic valves and induced significantly increased AR. The relatively large diameter was the reason that led to failure of periventricular closure. Accordingly, one contraindication of this procedure is that the diameter should be restrictive, usually no larger than 8 mm, from our preliminary experience. Similarly, patients with significant AP, AR, or both should not be selected as candidates for this procedure. The key to this procedure lies in the accurate and all-round echocardiographic evaluation of VSD. The echocardiographer must measure the largest diameter from different views. No solid view is suggested. The standard short-axis view, long-axis view, or any other view is not enough. The probe should be rotated from 0° to 180° to obtain an anatomic and true impression. We evaluated our patients by slightly adjusting the probe on the basis of the standard views, to delineate the heart defect as clearly as possible. Occasionally, the implanted device protruded a bit in the left ventricular outflow tract, without turbulence from the color Doppler. That is one reason why we need more patients and long-term follow-
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up, although no hemolysis, thromboembolism, or abnormal hemodynamics in the left ventricular outflow tract was observed during short-term follow-up. The preliminary and short satisfactory results of device closure of doubly committed subarterial VSD on beating hearts through a left anterior minithoracotomy with saddlelike occluders was achieved. However, more patients and long-term follow-up data are definitely needed. That is one significant drawback of our study.
References 1. Lue HC. Is subpulmonic ventricular septal defect an oriental disease? In: Lue HC, Takao A, eds. Subpulmonic ventricular septal defect. 1st ed. Tokyo: Springer-Verlag, 1986:3– 8. 2. Anzai T, Iijima T, Yoshida I, Sakata Y, Obayashi T, Ishikawa S. The natural history and timing of radical surgical operation for subpulmonic ventricular septal defects. Jpn J Surg 1991;21:487–93. 3. Bacha EA, Cao QL, Starr JP, Waight D, Ebeid MR, Hijazi ZM. Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results. J Thorac Cardiovasc Surg 2003;126:1718 –23. 4. Li F, Chen M, Qiu Z, Lu J, Wu W. A new minimally invasive technique to occlude ventricular septal defect using an occluder device. Ann Thorac Surg 2008;85:1067–71. 5. Gan CP, An Q, Lin K, et al. Perventricular device closure of ventricular septal defects: six months results in 30 young children. Ann Thorac Surg 2008;86:142– 6. 6. Xing QS, Pan SL, Zhuang ZY, et al. Minimally invasive perventricular device closure of an isolated perimembranous ventricular septal defect with a newly designed delivery system: preliminary experience. J Thorac Cardiovasc Surg 2009;137:556 –9. 7. Xing QS, Pan SL, An Q, et al. Minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass: multicenter experience and mid-term follow-up. J Thorac Cardiovasc Surg 2010;138:1409 –15. 8. Xing QS, Wu Q, Pan SL, Ren YY, Wa H. Transthoracic device closure of ventricular septal defects without cardiopulmonary bypass: experience in infants weighting less than 8 kg. Eur J Cardiothorac Surg 2011;40:591–7. 9. Tomita H, Arakaki Y, Ono Y, et al. Evolution of aortic regurgitation following simple patch closure of doubly committed subarterial ventricular septal defect. Am J Cardiol 2000;86:540 –2. 10. Tatsuno K, Konno S, Ando M, Sakakibara S. Pathogenetic mechanism of prolapsing aortic valve and aortic regurgitation associated with ventricular septal defect: anatomical, angiographic and surgical considerations. Circulation 1973; 48:1028 –37. 11. Tohyama K, Satomi G, Momma K. Aortic valve prolapse and aortic regurgitation associated with sub-pulmonic ventricular septal defect. Am J Cardiol 1997;79:1285–9. 12. Yacoub MH, Khan H, Stavri G, Shinebourne E, RadleySmith R. Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of valsalva, and ventricular septal defect. J Thorac Cardiovasc Surg 1997;113:253– 61. 13. Komai H, Naito Y, Fujiwara K, Noguchi Y, Nishimura Y, Uemura S. Surgical strategy for doubly committed subarterial ventricular septal defect with aortic cusp prolapse. Ann Thorac Surg 1997;64:1146 –9. 14. Chen Q, Chen LW, Wang QM, Cao H, Zhang GC, Chen DZ. Intraoperative device closure of doubly committed subarterial ventricular septal defects: initial experience. Ann Thorac Surg 2010;90:869 –73.
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