Ann Thorac Surg 1999;68:1400-1401
© 1999 The Society of Thoracic Surgeons
Case Reports
Transcatheter closure of multiple muscular ventricular septal defects using Gianturco coils
Haifa Abdul Latiff, MDa,
Mazeni Alwi, MRCPa,
Geetha Kandhavel, MRCPa,
Hasri Samion, MDa,
Robaayah Zambahari, FRCPa
a Department of Pediatric Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
Address reprint requests to Dr Alwi, Department of Pediatric Cardiology, National Heart Institute, 145, Jalan Tun Razak, Kuala Lumpur, Malaysia
e-mail: ijn{at}po.jaring.my
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Abstract
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A 10-month-old boy underwent operation to close a large secundum atrial septal defect and multiple muscular ventricular septal defects. Closure of the ventricular septal defects was unsuccessful and led to worsening cardiac failure and inability to wean the patient from mechanical ventilation. Transcatheter closure of the ventricular septal defects using Gianturco coils was undertaken. This technique is an effective alternative for closure of multiple muscular ventricular septal defects in infants and small children.
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Introduction
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Multiple muscular trabecular ventricular septal defects (VSDs) in infants and small children present a formidable challenge and remain a major cause of failure in surgical series [1]. Apical VSD closure through a left ventriculotomy is associated with left ventricular impairment and apical aneurysms [2]. Occasionally in the setting of multiple cardiac lesions, the hemodynamic importance of multiple muscular VSDs is fully appreciated only in the early postoperative period when the other abnormalities have been rectified. These VSDs, which previously were thought to be inconsequential, can cause severe cardiac failure and inability to wean the patient from assisted ventilation. Reoperation can further aggravate the hemodynamic instability and increase the possibility of failure of effective closure. We report here successful transcatheter closure of such defects using Gianturco coils.
A 10-month-old male infant weighing 5.7 kg was referred because of cardiac failure and recurrent chest infections. There was a grade 2/6 systolic murmur with a loud second heart sound. The chest radiograph showed cardiomegaly and plethoric lung fields. Echocardiography revealed a large secundum atrial septal defect with almost total absence of the atrial septum. In addition, a small perimembranous VSD and multiple muscular trabecular VSDs extending from the midseptum apically were noted. The apical defect measured 3.5 mm in diameter, and the midseptal defects resembled irregular, tubular channels of 1.5 to 2.0 mm in diameter within the trabecular septum. At cardiac catheterization, the calculated pulmonary to systemic flow ratio was 4:1 with a mean pulmonary artery pressure of 50 mm Hg compared with a mean aortic pressure of 63 mm Hg.
After closure of the atrial septal defect, a smaller oval patch was placed transatrially over the apical right ventricular aspect of the ventricular septum in an attempt to close the muscular VSDs. Contrary to expectations, the patient continued to require a high level of ventilatory support postoperatively. The chest radiograph showed persistence of cardiomegaly and pulmonary plethora (Fig 1). Echocardiography revealed a major residual left-to-right shunt. By the sixth postoperative day, the patient was in severe cardiac failure with generalized edema and marked hepatomegaly.
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Fig 1. Chest radiograph made after closure of the ventricular septal defects shows persistent cardiomegaly and pulmonary plethora.
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After informed consent was obtained from the parents, the patient underwent cardiac catheterization and transcatheter closure of the muscular VSDs using Gianturco coils. Hand ventilation with a high inspired oxygen fraction was used during the procedure. The pulmonary artery pressure was 52/24 mm Hg (mean pressure, 31 mm Hg), and the aortic pressure was 85/57 mm Hg (mean pressure, 65 mm Hg). After the defects were identified by left ventriculography, a 5F Judkins Right catheter over a 0.035-inch hydrophilic guidewire (Terumo Corp) was passed transarterially in an attempt to probe the VSDs from the left ventricular side for coil deployment under fluoroscopy and transesophageal echocardiographic guidance. This provoked an episode of sustained ventricular tachycardia and hypotension, which resolved with direct-current cardioversion, epinephrine, and a loading dose of lidocaine hydrochloride.
Consequently the defects were crossed transvenously from the right ventricle using the same catheter and guidewire, starting with the most apical defect. Three coils were deployed sequentially in this defect alone. Four other coils were deployed in the same manner for the other defects. Altogether one coil 10 mm in diameter and 10 cm long and six coils 8 mm in diameter and 5 cm long were deployed. Color Doppler studies at the end of the procedure showed that the shunt had been reduced considerably. After coil deployment, the condition of the patient improved remarkably with complete regression of the generalized edema and hepatomegaly. He was asymptomatic and free from medications 3 months after the procedure, and 1 month later, chest radiography revealed a normal heart size (Fig 2). An echocardiogram revealed a small residual apical VSD. At repeat cardiac catheterization after 6 months, there was a small residual defect (pulmonary to systemic flow ratio 1.2:1), and the pulmonary artery pressure was normal.
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Fig 2. Chest radiograph made at 4-month follow-up shows a normal heart size with Gianturco coils in situ (arrow).
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Comment
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To date, a device not specifically designed for closure of VSDs, the Rashkind double-umbrella device, the Lock clamshell device, and the buttoned device have been used with varying degrees of success in membranous and muscular defects [3, 4]. Of concern, however, are the hemodynamic instability, the dysrhythmias, and the need of transfusions and admission to the intensive care unit after the procedure [5]. The use of these devices requires that a long sheath over a stiff dilator be passed across the VSD. This is a major potential source of morbidity and can preclude device use in many infants and small children, especially if more than one device is needed. In this respect, intraoperative deployment has been suggested as a safer alternative [6]. Gianturco coils have been widely used to close unwanted vascular communications and small- to moderate-sized patent ductus arteriosus [7]. The coil can be delivered through a conventional 4F or 5F end-hole catheter, which can be passed transvenously or transarterially across the VSDs using a hydrophilic guidewire. This makes the procedure potentially less traumatic especially in infants. In addition, we believe that the pliable nature of these spring coils makes them suitable for "Swiss-cheese" VSDs in the muscular septum.
In conclusion, closure of multiple muscular VSDs using Gianturco coils is a feasible, reasonable alternative. The method warrants further study to evaluate its safety and efficacy.
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References
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Serraf A., Lacour-Gayet F., Bruniaux J., et al. Surgical treatment of isolated multiple ventricular septal defects. Logical approach in 130 cases. J Thorac Cardiovasc Surg 1992;103:437-443.[Abstract]
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Hanna B., Colan S.D., Bridges N.D., Mayer J.E., Castaneda A.R. Clinical and myocardial status after left ventriculotomy for ventricular septal defect closure [Abstract]. J Am Coll Cardiol 1991;17(Suppl):110A.
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Bridges N.D., Perry S.B., Keane J.F., et al. Preoperative transcatheter closure of congenital muscular ventricular septal defects. N Engl J Med 1991;324:1312-1317.[Abstract]
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Sideris E.B., Walsh K.P., Haddad J.L., Chen C.R., Ren S.G., Kulkarni H. Occlusion of congenital ventricular septal defects by the buttoned device. "Buttoned device" Clinical Trials International Register. Heart 1997;77:276-279.[Abstract/Free Full Text]
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Laussen P.C., Hansen D.D., Perry S.B., et al. Transcatheter closure of ventricular septal defects. Anesth Analg 1995;80:1076-1082.[Abstract]
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Chaturvedi R.R., Shore D.F., Yacoub M., Redington A.N. Intraoperative apical ventricular septal defect closure using a modified Rashkind double umbrella. Heart 1996;76:367-369.[Abstract/Free Full Text]
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Lloyd T.R., Fedderly R., Mendelsohn A.M., Sandhu S.K., Beekman R.H., III Transcatheter occlusion of patent ductus arteriosus with Gianturco coils. Circulation 1993;88:1412-1420.[Abstract/Free Full Text]
Accepted for publication March 15, 1999.
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Abstract
Introduction
