Mirza M K, Abqari S, Haseen A, Yadav M.Cardiol Young. 2023 Apr;33(4):539-545. doi: 10.1017/S1047951122001147. Epub 2022 May 2.PMID: 35491695
Take Home Points:
- Device closure of perimembranous ventricular septal defects is feasible in patients ≤ 10 kg in weight.
- Careful attention must be given to aortic and tricuspid valve interactions using intraprocedural TEE guidance.
- Although a retrograde approach was preferred amongst the authors, flexibility regarding approach is needed to limit complications.
Commentary from Dr. Arash Salavitabar (Ann Arbor, MI, USA), section editor of Congenital Heart Disease Interventions Journal Watch:
The authors of this retrospective single-center study aimed to evaluate the efficacy and safety of transfemoral device closure of perimembranous ventricular septal defects (VSDs) in patients ≤ 10 kg in weight. The authors approached this procedure with initial left ventricular angiography and chose the device based on the presence of a ventricular septal aneurysm, length of subaortic rim, and VSD diameter. The VSD device was chosen to be 1-2mm greater than the largest measurement of VSD color flow by TEE.
Over a 7-year period, 16 patients underwent this procedure at a median age of 11 months (IQR 9-15.5) and median weight 8.3 kg (7.2-9.5). The median defect size by TEE was 6.8mm (6-8.5) and median VSD device diameters were 6.2 mm (5.7-8.3). The following devices were use: Amplatzer Duct Occluder II (n=6); Lifetech Symmetric Membranous VSD Occluder (n=4), KONAR-MF VSD Occluder (n=4), Lifetech Eccentric Membranous VSD Occluder (n=1), and Occlutech PmVSD Occluder (n=1). A retrograde deployment was preferred (14/18 total device implantation attempts). The only comment regarding choice of device was regarding the tendency to use symmetric double-disc occluders in all but one patient.
The procedural success rate was 88% (n=14). Of the two unsuccessful device placements, one involved development of moderate aortic regurgitation via retrograde approach and moderate TR via antegrade approach. The other unsuccessful case was a patient who developed progressive, moderate AR over 2 days post-procedure. Each of these patients required surgery. There were no device embolizations. On median follow-up of 40.5 months (25-64), none developed complete heart block.
This paper nicely showed that this procedure can be performed safely in small patients with perimembranous VSDs, with careful consideration to VSD anatomy, aortic valve rim, and interactions with aortic valve and tricuspid valve apparatus. Importantly, the majority of the devices used by the authors are not available in the United States, which emphasizes the importance of formal investigation and future FDA approval of additional device options for this indication. Similar studies are needed to understand the details of ventricular septal anatomy, optimal device choice, and patient selection.