Kamran Mirza M, Shaad Abqari, Azam Haseen and Mayank Yadav
Take Home Points
- Patients ≤10kg with least a 3mm tissue rim separating the VSD from the AV or TV, and no/minimal baseline aortic regurgitation were considered for device closure with a 90% success rate
- ADO I devices were used for defects with a septal aneurysm, ADO II for smaller defects, and muscular VSD device for larger defects via retrograde and antegrade approaches
Commentary from Dr. Arash Salavitabar (Ann Arbor, MI, USA), section editor of Congenital Heart Disease Interventions Journal Watch:
The authors report on the results of a retrospective single-center study on the feasibility and short-term outcomes of percutaneous ventricular septal defect (VSD) closure in patients weighing ≤10kg. Patients were included is they had a hemodynamically significant VSD by both clinical and echocardiographic and catheterization criteria. Patients ≤10kg were considered amenable for device closure if there was at least a 3mm tissue rim separating the defect from the AV or TV, and there was no or minimal baseline aortic regurgitation.
This procedure was performed in 50 patients, 47 of which were performed under conscious sedation and all of which were approached via the right internal jugular vein and right femoral vein and artery. Mean patient weight was 7.46 ± 1.89 kg (2.3–10 kg) and mean age was 19.4 ± 11.88 months (4–48 months). VSD types consisted of 35 (70%) perimembranous, 7 (14%) upper muscular, 3 (6%) mid-muscular, 2 (4%) lower muscular, 3 (6%) outlet muscular. Pulmonary hypertension was present in 29 (58%) patients, which was defined based on mPAP >25mmHg (as opposed to being defined by pulmonary vascular resistance). Retrograde device closure was performed in 27 (54%) and antegrade device closure was performed in 15 (38%) via RFV and 3 (6.6%) with mid-muscular and lower muscular defects via RIJ access. Device choice was based on VSD characteristics, with a size 1-2mm larger than the largest defect diameter on the RV side. ADO I devices (15 cases, 30%) were used for defects with a septal aneurysm, ADO II (27 cases, 52%) for smaller defects, and muscular VSD device for larger defects.
Device closure was successful in 45 patients (90%), 5 (12%) of which had minimal intra-device residual flow at discharge which had resolved by 1-month follow-up. There were no incidences of aortic or tricuspid regurgitation. There was 1 (2%) immediate device embolization. Unsuccessful attempts included device embolization of undersized ADOII, severe bradycardia during delivery sheath advancement via an AV loop, aortic regurgitation caused by ADOII disc, and poor device position, each of which resulted in conversion to surgical closure.
Of the devices used in this study, the authors concluded that the most suitable device for closure of VSDs which are not very large (>5mm) and perimembranous in location is ADOII because of its feasibility to deliver it via a retrograde approach without forming an AV loop, as well as its softer profile to limit the chance of injury to adjacent structures.