Thejaswi P, Sagar P, Sivakumar K, Chattopadhyay A, Francis E, Surucu M, et al. International Experience of Transcatheter Sinus Venosus Defect Closure in Children and Adolescents. Pediatric Cardiology. 2026. doi:10.1007/s00246-026-04200-8.
PubMed: https://pubmed.ncbi.nlm.nih.gov/41863591/
Take-Home Points
- This international multicenter registry evaluated 54 children and adolescents (<18 years) undergoing transcatheter closure of superior sinus venosus defects (SVD) using covered stents.
- Procedural success was exceptionally high at 98.1%, with only one patient requiring surgical intervention following stent embolization.
- Approximately two-thirds of patients were successfully treated with a single covered stent, simplifying intervention compared with adult cohorts.
- Pulmonary vein protection techniques were required in nearly half of all procedures (48%), underscoring the importance of meticulous procedural planning.
- During a median follow-up of 38 months (up to 174 months), there were no cases of late stent thrombosis, no rhythm disturbances, and only three reinterventions for residual shunting.
- Importantly, no patient required subsequent stent re-dilation despite somatic growth, addressing one of the major concerns regarding use of fixed-diameter covered stents in pediatric patients.
Commentary from Dr. Varun Aggarwal (Wilmington, DE, USA), editor-in-chief of Congenital Heart Disease Journal Watch:
Few developments in congenital heart intervention have challenged long-standing surgical paradigms as dramatically as transcatheter closure of superior sinus venosus defects. For decades, sinus venosus atrial septal defects accompanied by anomalous pulmonary venous drainage were considered among the most reliable indications for surgical repair. Unlike secundum ASDs, these lesions were viewed as fundamentally unsuitable for percutaneous therapy because of their complex anatomy and associated pulmonary venous abnormalities.
That assumption is rapidly disappearing.
This multinational registry from Thejaswi and colleagues represents an important milestone because it focuses specifically on children and adolescents, a population in whom enthusiasm for transcatheter sinus venosus defect closure has been tempered by an important concern: growth. While covered stents have demonstrated impressive results in adults, many clinicians have questioned whether a fixed-diameter stent implanted in childhood could accommodate future somatic development without creating superior vena caval or pulmonary venous obstruction later in life.
The present study offers the strongest evidence to date that these concerns may be less significant than initially feared.
Among 54 pediatric patients treated across 12 international centers, procedural success approached 100%. These results are particularly impressive given the anatomical complexity of the lesions involved. Nearly one-third of patients had bilateral superior vena cavae, and approximately 11% demonstrated high-draining pulmonary veins, circumstances traditionally viewed as adding substantial complexity to intervention. Yet successful transcatheter repair remained achievable in the vast majority of cases.
Perhaps the most clinically important finding relates to growth potential. Pediatric interventional cardiologists are accustomed to managing lesions that require reintervention as children mature. Balloon-expandable stents implanted in the pulmonary arteries, aortic arch, and systemic venous pathways frequently require later expansion to accommodate somatic growth. Sinus venosus defect closure presents a different challenge because aggressive future stent expansion carries the theoretical risk of compressing or distorting the redirected right upper pulmonary vein.
The reassuring observation from this registry is that no patient required stent re-dilation during follow-up extending to nearly 15 years in some cases. The authors hypothesize that because superior vena caval diameters in many children already approach adult dimensions, appropriately sized stents may provide sufficient long-term accommodation without the need for subsequent enlargement. While longer follow-up remains necessary, these data represent an important step toward addressing a major barrier to broader adoption of transcatheter therapy in younger patients.
Another notable finding is the relative procedural simplicity observed in children compared with adults. Two-thirds of patients were successfully treated with a single stent, substantially higher than reported in broader international registries. Smaller anatomy often permitted use of shorter covered stents, smaller delivery systems, and more straightforward procedural planning. This observation challenges the assumption that pediatric interventions are necessarily more complex. In the case of sinus venosus defect closure, younger age may facilitate procedural success in carefully selected anatomies.
The study also highlights how rapidly procedural technique has evolved. Nearly half of patients underwent pulmonary vein protection during stent deployment, a strategy that has emerged as one of the defining innovations of modern sinus venosus defect intervention. Likewise, jugular railroad techniques, specialized stabilization methods, and advanced imaging approaches have expanded procedural feasibility and improved safety. These refinements illustrate how transcatheter closure has progressed from a novel concept to a reproducible structural intervention.
For pediatric cardiologists, one of the most encouraging observations is the remarkably low incidence of serious complications. Acute complications were rare, and long-term outcomes were favorable. There were no late stent thromboses, no significant rhythm disturbances, and only two cases of mild right upper pulmonary vein gradients. Reintervention rates remained low, and most residual shunts were successfully addressed with catheter-based techniques.
The unavoidable question, of course, is how these outcomes compare with surgery.
Surgical sinus venosus defect repair remains highly effective, with excellent long-term survival and durable hemodynamic results. However, surgery is not entirely without cost. Sternotomy, cardiopulmonary bypass, hospitalization, sinus node dysfunction, and occasional systemic or pulmonary venous obstruction remain relevant considerations. Transcatheter therapy offers the possibility of avoiding many of these burdens while achieving comparable hemodynamic correction.
The authors appropriately refrain from declaring transcatheter closure superior to surgery. Instead, the message is more nuanced. For anatomically suitable pediatric patients, catheter-based closure appears feasible, safe, and durable in the medium term. This shifts the clinical conversation away from whether transcatheter closure is possible toward determining which patients are best served by each strategy.
An important lesson from this registry is the critical role of patient selection. Every patient underwent detailed anatomical assessment, including careful evaluation of anomalous pulmonary venous drainage and balloon interrogation before intervention. Success depended on demonstrating unobstructed redirection of pulmonary venous return prior to stent implantation. These results therefore reflect not merely technical proficiency but careful adherence to selection criteria.
The study also emphasizes the growing globalization of congenital heart innovation. Centers from Europe, Asia, the Middle East, and North America contributed experience, suggesting that successful implementation is not limited to a handful of highly specialized institutions. As expertise spreads and equipment continues to improve, eligibility for transcatheter repair may further expand.
Ultimately, this report represents another important step in the evolution of structural congenital intervention. Sinus venosus defects were once considered exclusively surgical lesions. The current data suggest that, for many carefully selected children and adolescents, that paradigm has changed. While lifelong surveillance remains essential, the excellent procedural success, favorable medium-term outcomes, and absence of growth-related complications are highly encouraging.
The future challenge may no longer be proving that transcatheter sinus venosus defect closure works. Rather, it will be determining how best to integrate this therapy into routine pediatric congenital heart practice.
Clinical Perspective
Transcatheter closure of superior sinus venosus defects using covered stents is highly feasible in selected children and adolescents, achieving a procedural success rate exceeding 98% with excellent medium-term outcomes. Importantly, no patient required stent re-dilation despite ongoing somatic growth, providing reassurance about the long-term applicability of this strategy in pediatric populations. Careful patient selection, pulmonary vein assessment, and longitudinal follow-up remain essential.
