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TRANSCATHETER CLOSURE OF VSD: WHAT CAN BE SAFELY DONE?
Jonas D. Del Rosario, MD, FPCCClinical Associate ProfessorUP College of Medicine
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No disclosures
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First DO NO HARM
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Objectives
What types of VSD are amenable for catheter closure at this time
How to select and screen patients who are amenable for catheter closure of VSD
Concerns/Complications Present our limited experience with the
use of VSD coil in the Philippines
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Ventricular Septal Defect
Most common congenital cardiac malformation
Surgery is the standard method for closure of VSD Mortality rate in high volume centers is less
than 0.6% to 1.8% Complication < 1% Complete heart block is less than 1%
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VSD Closure with PFM VSD Coils
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Transcatheter closure of VSD (TCCVSD)
Remains to be the most challenging interventional procedure in CHD
Various devices have been used with a high degree of effectiveness to primarily close muscular and perimembranous VSD
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Advantages of TCC of VSD
Avoids median sternotomy scar Avoids cardiopulmonary bypass Shorter hospital stay Shorter recovery period
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Indication for Closure of VSD
Hemodynamically significant Qp:Qs > 1.5
LA or LV enlargement Cardiomegaly on CXR Failure to Thrive Previous episode of Infective
Endocarditis
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Soft Indications for VSDDeveloped since catheter closure
Better psychosocial impact on patient
Avoid the inherent problems related to stigma of having a heart defect
Employability Health Insurance Heavy vehicle license Sports participation (as a
professional)
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Concerns/Complications Complexity of procedure Steep Learning Curve Applicability in selected group Proximity of aortic and tricuspid valve Conduction system (arrhythmias, heart block) Residual shunt with risk of infective endocarditis Mechanical haemolysis Embolization
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Proper selection of patients is the KEY.
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What Is Not Amenable For TCC
AV Canal Type (Inlet)
Large Perimembranous VSD(Unrestrictive)
Subpulmonic VSD
Multiple (Swiss Cheese) VSDs
VSD as a component of a more complex lesion
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Amplatzer Muscular VSD occluder
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Muscular VSD Device
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Anterior Muscular VSD device
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Amplatzer PM VSD Occluder (AVSO)
First device specifically designed for membranous VSD
First reported by Hijazi et al 2002 and Thanopoulos in 2003
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Perimembranous VSD device
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Amplatzer PM VSD occluder (AVSO)
Became the most popular device to close VSDs worldwide with good short and medium term outcome
Occurrence of complete heart block in an unpredictable manner even after years post-implantation has currently tempered the enthusiasm of the interventional community (Incidence 1-5%)
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Heart Block of AVSO
Rim of the VSD closed by AVSO remains under continuous pressure due to the stenting philosophy of this device
This can cause trauma to the neighboring conduction system
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What Type of Can Be Safely Occluded
Muscular VSDMidmuscular/Apical
Perimembranous VSDRestrictiveVentricular Septal AneurysmVSD rim > 3mm from aortic ValveDefect is <6mm from RV sidePresents like a “FUNNEL”
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The PFM VSD Coil
• Novel attachment mechanism • Stiff distal loops, covered with polyester filaments
5.5F delivery catheter; Distal Coil Diameter: 8,10,12,14 mm
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Nit Occlud Lê VSD – Deutsche Studie4 Zentren 35 Fälle
eine Heilbehandlung (Köln)
VenezuelaDr. Borges
12 Patienten
BrasilienDr. Pedra
Dr. ChamieDr. SimoesDr. Rossi
28 Patienten
VietnamDr. TrieuDr. NhanDr. HuanDr. HieuDr. Binh
35 Patienten
ThailandDr. Kritvikrom 14 Patienten
MalaysiaDr. Wong
Dr. Samion6 Patienten
ArgentinienDr. GranjaDr. Peirone4 Patienten
Saudi ArabienDr. GalalDr. Ekram
9 Patienten
ÄgyptenDr. Sayhed3 Patienten
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VSD Coil (Nit-Occlud Le VSD Coil)
Conical-shaped nitinol coil More flexible, softer and conforms to the
shape of VSD Less traumatic
Used for: Perimembranous VSD with aneurysmal
pouch and muscular VSD Muscular VSD
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Shapes of membranous and muscular VSD
Courtesy Dr. L. Simoes
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VSD with VSA formation
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VSD with VSA formation
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Occlusion of VSD using the PFM VSD Coil
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117 Patients with restrictive VSDPerim. VSD (n=97) Musc. VSD (n=10) Subpulm. VSD (n=10)
International Experience with the PFM VSD Coil
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International Experience with the PFM VSD Coil
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International Experience with the PFM VSD Coil
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International Experience with the PFM VSD Coil
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International Experience with the PFM VSD Coil
Device Displacement: noneDevice Fracture: noneDevice Embolization: 2 (transcath. removal within 3 hours)
AI: n = 2 (I-II°)TR: n = 2 (II°)
Hemolysis: n = 5 4 transient 1 severe, device surgically removed
Problems of conduction system: none!
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Occlusion of VSD using the PFM VSD Coil
Coil SelectionDistal coil diameter is• at least double the minimal diameter (right ventricular opening) • equal or 1-2mm larger than left ventricular diameter of VSD.
Distal Loop Diameter: 8 mm10 mm12 mm14 mm
Prox. Loop Diameter: 6 mm6 mm6 mm8 mm
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VSD Coil (UP-PGH) experience 5 patients 3y – 29 y VSD with Ventricular septal
aneurysm 1st case was done 3 years ago Last 4 cases done 1 year ago Total occlusion after 1 month No incidence of heart block, CVA, IE
and death
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The implantation procedure
Guidance by TOE or TTETransvenous implantation
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PDA device to close VSDs?
Perimembranous VSD which are “conical” (like a PDA type A)
Distance from the aortic valve is >4mm Amplatz Duct Occluder
Nguyen Lan Hieu, MD, PhD Hanoi Medical University-Vietnam Heart
Institute Performed in some patients in Heart Center
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Pm VSD (conical)
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VSD (conical)
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Summary
TCC of VSD is a complex interventional procedure that can be performed effectively and safely in well selected patients
Muscular VSDs can still be closed by Amplatzer devices
VSD coils are safe in aneurysmatic OR conical perimembranous VSDs and muscular VSD which have a distance from the AV node
Majority of the perimembranous VSDs should be closed by surgery at this time until a better device can be made that will not produce heart block at a higher rate
Long-term follow-up is important
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Thank you for your attention