Breatnach CR, Kenny D, Linnane N, Al Nasef M, Ng LY, McGuinness J, McCrossan B, Nölke L, Oslizlok P, Redmond M, Walsh K.Pediatr Cardiol. 2021 Oct;42(7):1539-1545. doi: 10.1007/s00246-021-02638-6. Epub 2021 Jun 3.PMID: 34081172
Take Home Points:
- Using a team approach, perimembranous ventricular septal defects can be closed via a minimally invasive, “pseudo-percutaneous” approach with good safety and efficacy.
Commentary from Dr. Konstantin Averin (Edmonton), catheterization section editor of Pediatric Cardiology Journal Watch:
Percutaneous closure of perimembranous ventricular septal defects (pmVSD) is experiencing a resurgence as cumulative experience with newer devices demonstrates a favorable safety profile. The approach is generally limited to larger children due to the need for relatively large delivery systems. The authors undertook to describe their novel approach to closing pmVSDs in small children via a surgical right carotid cut-down.
Patients ≥5kg were included if they had evidence of a hemodynamically significant pmVSD without coronary cusp prolapse or aortic insufficiency. Procedures were done in a hybrid cardiac catheterization laboratory with both surgical and interventional teams. A 7 French sheath was placed in the right carotid artery via surgical cut down and the defects were primarily assessed via trans-esophageal echocardiography. The remainder of the procedural steps are summarized in the text but are generally similar to other descriptions of retrograde pmVSD closure. The Figure below demonstrates fluoroscopy of the steps in closure.
Between December 2016 and April 2020, 18 infants (median [IQR] age 7 [5-9] months and weight 7.1 [6.5-7.8] kg) underwent attempted pmVSD closure via this approach. Outcomes are summarized in the table below. Most patients (15/18) had their defects closed successfully with the remaining 3 requiring conversion to open repair (1 – device embolization, 1 – tricuspid valve injury, 1 – device instability). Most patients were discharge after overnight observation on the ward. All 12 patients who had follow up assessment of carotid artery demonstrated no abnormalities.
While not revolutionary, this very interesting report brings together 3 current trends in pediatric cardiac catheterization – the increasing interest in percutaneous closure of pmVSD, use of the carotid artery for interventions in young children, and a collaborative approach to dealing with issues in congenital heart disease. The authors are to be commended for their innovative thinking and good outcomes.