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Transcatheter closure of congenital ventricular septal defects in adults
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Letters to the Editor
Transcatheter closure of congenital ventricular septal defects in adults Mid-term results and complications: Few more considerations Massimo Chessa ⁎, Jaspal S. Dua, Mario Carminati Centro di Cardiologia Pediatrica e Cardiopatie Congenite dell'Adulto Policlinico San Donato IRCCS, Italy
a r t i c l e
i n f o
Article history: Received 19 May 2009 Accepted 24 May 2009 23 June June 2009 2009 Available online 13 Keywords: Ventricular septal defect Adult with congenital heart defects GUCH ACHD Device
We read with great interest, the letter by Bialkowski and colleagues [1]. We would like to respond to the authors' comments. These comments comply with the principles of ethical publishing in the International Journal of Cardiology [2]. The letter is quite topical as it provides the opportunity to stress a major point of the percutaneous closure of ventricular septal defect (VSD): the choice of the optimal device. We completely agree with the authors that one of the most important issues in this procedure is to avoid complete atrio-ventricular block (cAVB). But the evidence in the literature is scarce as to whether this is entirely due to compression of conduction tissue by the retention discs. The Amplatzer perimembranous VSD occluder (pmVSDO) was developed to address the limitations of the Amplatzer muscular VSD occluder (mVSDO) in respect to closing pmVSDs. The high incidence of cAVB closing pmVSD in paediatric age previously published by our team was related mostly to the patient age and weight [3]. In fact, the results of the European Registry also reflect the same risk factors [by multivariate analysis] for development of cAVB: age and weight. In the adult population, we have not experienced a significant incidence of cAVB and we have not found any relationship of cAVB with any specific device [4,5]. Some authors have suggested that the presence of an aneurysm of ventricular septum or of an oversized device are associated with a higher risk of cAVB. However, most of the data in the literature does not support these statements at all [6]. It is clear that for the time being we do not have an ideal device; but we are not sure that choosing a mVSDO instead of a pmVSDO (as suggested by the authors) for transcutaneous pmVSD closure is the solution. We believe that the device needs to be softer, with a smaller central waist, like the new Amplatzer Duct Occluder (ADO) II device developed for transcutaneous patent ductus arteriosus (PDA) occlusion.
⁎ Corresponding author. Centro di Cardiologia Pediatrica e Cardiopatie Congenite dell'Adulto Policlinico San Donato IRCCS Via Morandi, 30 20097 San Donato Milanese (MI), Italy. Tel.: +39 02 52774328; fax: +39 02 52774459. E-mail address: [email protected] (M. Chessa).
0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.05.043
In response to the second comment of the authors, we would say that in our series, the mean thickness of the interventricular septum in adults ranged from 7 to 11 mm. We never experienced any significant problems related to closing pmVSDs with the mVSDO in terms of efficacy, residual shunts, cAVB etc. Occasionally, we did have a device where the right disc did not conform to its ideal shape very well. But this happened exclusively in children, who had thinner IVS than adults. Hence, this non-conformity can't be related to the length of the central waist of the device. These patients did not have any problems with tricuspid valve function post procedure. Therefore, this non-conformity can't be related to entrapment of tricuspid valve apparatus either. Could this be related to the right ventricular trabeculations? Possibly, but we can't be certain. It could also be related to the fact the IVS is not a flat structure. It is a curvilinear planar 3D structure. The anatomy of the septum is also quite diverse, especially in the right ventricular apical part. Hence a softer device will probably conform more to the curvature of the septum than the current, more rigid devices. In the rest of our patients the 2 discs appeared parallel and well conformed at the end of the procedure (some of these patients had prominent trabeculations). So it remains uncertain, why the right disc may conform well in some and not in others. Yours sincerely The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [2]. References [1] Bialkowski J, Szkutnik M, Kusa J, Siszer R. Few comments regarding transcatheter closure of congenital perimembranous and muscular ventricular septal defects. Int J Cardiol 2010;145:69. [2] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50. [3] Butera G, Carminati M, Chessa M, Piazza L, Micheletti A, Negura DG, et al. Transcatheter closure of perimembranous ventricular septal defects: early and long-term results. J Am Coll Cardiol 2007;50(12):1189–95 Sep 18. [4] Carminati M, Butera G, Chessa M, Drago M, Negura D, Piazza L. Transcatheter closure of congenital ventricular septal defects with Amplatzer septal occluders. Am J Cardiol 2005;96(12A):52L–8L Dec 19. [5] Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defects: results of the European Registry. Eur Heart J 2007;28(19):2361–8 Oct. [6] Predescu D, Chaturvedi RR, Friedberg MK, Benson LN, Ozawa A, Lee KJ. Complete heart block associated with device closure of perimembranous ventricular septal defects. J Thorac Cardiovasc Surg 2008;136(5):1223–8 Nov.
Letters to the Editor
Transcatheter closure of congenital ventricular septal defects in adults Mid-term results and complications: Few more considerations Massimo Chessa ⁎, Jaspal S. Dua, Mario Carminati Centro di Cardiologia Pediatrica e Cardiopatie Congenite dell'Adulto Policlinico San Donato IRCCS, Italy
a r t i c l e
i n f o
Article history: Received 19 May 2009 Accepted 24 May 2009 23 June June 2009 2009 Available online 13 Keywords: Ventricular septal defect Adult with congenital heart defects GUCH ACHD Device
We read with great interest, the letter by Bialkowski and colleagues [1]. We would like to respond to the authors' comments. These comments comply with the principles of ethical publishing in the International Journal of Cardiology [2]. The letter is quite topical as it provides the opportunity to stress a major point of the percutaneous closure of ventricular septal defect (VSD): the choice of the optimal device. We completely agree with the authors that one of the most important issues in this procedure is to avoid complete atrio-ventricular block (cAVB). But the evidence in the literature is scarce as to whether this is entirely due to compression of conduction tissue by the retention discs. The Amplatzer perimembranous VSD occluder (pmVSDO) was developed to address the limitations of the Amplatzer muscular VSD occluder (mVSDO) in respect to closing pmVSDs. The high incidence of cAVB closing pmVSD in paediatric age previously published by our team was related mostly to the patient age and weight [3]. In fact, the results of the European Registry also reflect the same risk factors [by multivariate analysis] for development of cAVB: age and weight. In the adult population, we have not experienced a significant incidence of cAVB and we have not found any relationship of cAVB with any specific device [4,5]. Some authors have suggested that the presence of an aneurysm of ventricular septum or of an oversized device are associated with a higher risk of cAVB. However, most of the data in the literature does not support these statements at all [6]. It is clear that for the time being we do not have an ideal device; but we are not sure that choosing a mVSDO instead of a pmVSDO (as suggested by the authors) for transcutaneous pmVSD closure is the solution. We believe that the device needs to be softer, with a smaller central waist, like the new Amplatzer Duct Occluder (ADO) II device developed for transcutaneous patent ductus arteriosus (PDA) occlusion.
⁎ Corresponding author. Centro di Cardiologia Pediatrica e Cardiopatie Congenite dell'Adulto Policlinico San Donato IRCCS Via Morandi, 30 20097 San Donato Milanese (MI), Italy. Tel.: +39 02 52774328; fax: +39 02 52774459. E-mail address: [email protected] (M. Chessa).
0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.05.043
In response to the second comment of the authors, we would say that in our series, the mean thickness of the interventricular septum in adults ranged from 7 to 11 mm. We never experienced any significant problems related to closing pmVSDs with the mVSDO in terms of efficacy, residual shunts, cAVB etc. Occasionally, we did have a device where the right disc did not conform to its ideal shape very well. But this happened exclusively in children, who had thinner IVS than adults. Hence, this non-conformity can't be related to the length of the central waist of the device. These patients did not have any problems with tricuspid valve function post procedure. Therefore, this non-conformity can't be related to entrapment of tricuspid valve apparatus either. Could this be related to the right ventricular trabeculations? Possibly, but we can't be certain. It could also be related to the fact the IVS is not a flat structure. It is a curvilinear planar 3D structure. The anatomy of the septum is also quite diverse, especially in the right ventricular apical part. Hence a softer device will probably conform more to the curvature of the septum than the current, more rigid devices. In the rest of our patients the 2 discs appeared parallel and well conformed at the end of the procedure (some of these patients had prominent trabeculations). So it remains uncertain, why the right disc may conform well in some and not in others. Yours sincerely The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [2]. References [1] Bialkowski J, Szkutnik M, Kusa J, Siszer R. Few comments regarding transcatheter closure of congenital perimembranous and muscular ventricular septal defects. Int J Cardiol 2010;145:69. [2] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50. [3] Butera G, Carminati M, Chessa M, Piazza L, Micheletti A, Negura DG, et al. Transcatheter closure of perimembranous ventricular septal defects: early and long-term results. J Am Coll Cardiol 2007;50(12):1189–95 Sep 18. [4] Carminati M, Butera G, Chessa M, Drago M, Negura D, Piazza L. Transcatheter closure of congenital ventricular septal defects with Amplatzer septal occluders. Am J Cardiol 2005;96(12A):52L–8L Dec 19. [5] Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defects: results of the European Registry. Eur Heart J 2007;28(19):2361–8 Oct. [6] Predescu D, Chaturvedi RR, Friedberg MK, Benson LN, Ozawa A, Lee KJ. Complete heart block associated with device closure of perimembranous ventricular septal defects. J Thorac Cardiovasc Surg 2008;136(5):1223–8 Nov.