Ann Thorac Surg 2008;85:192-194. doi:10.1016/j.athoracsur.2007.07.018
© 2008 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Device Closure of Perimembranous Ventricular Septal Defects With a Minimally Invasive Technique in 12 Patients
Xiang Jun Zeng, MD, PhDa,*,
Shan Quan Sun, MDa,
Xu Fa Chen, MDa,
Xiao Jing Ma, MDb,
Yan Hong Luo, MDb,
Yeong Phang Lim, MDc,
Liang Tao, MDa
a Cardiac Surgical Department, WuHan Asia Heart Hospital, WuHan, China
b Ultrasonic Department, WuHan Asia Heart Hospital, WuHan, China
c Cardiothoracic Surgical Department, Singapore National Heart Center, Singapore, China
Accepted for publication July 9, 2007.
* Address correspondence to Dr Zeng, WuHan Asia Heart Hospital, WuHan, 430022, China (Email: zengxiangjun{at}sohu.com).
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Abstract
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Background: Both surgical management and percutaneous device closure of perimembranous ventricular septal defects without cardiopulmonary bypass have drawbacks and limitations. This report describes the experience with intraoperative device closure of perimembranous ventricular septal defects without cardiopulmonary bypass by a minimally invasive technique.
Methods: Twelve patients who had perimembranous ventricular septal defects underwent perventricular closure by a minimally invasive incision without cardiopulmonary bypass. A subxiphoid minimally invasive incision was performed. The right ventricle free wall was punctured, and a guidewire was introduced into the right ventricular cavity. A delivery sheath was advanced over the wire and through the defect into the left ventricular cavity under the guidance of transesophageal echocardiography. The device was released under the guidance of transesophageal echocardiography without cardiopulmonary bypass.
Results: The procedure was successful in the 12 patients. Patients stayed in the intensive care unit 1 day and were in the hospital 4 days. At follow-up of 2 to 4 months, there was no operative mortality, atrioventricular block, new aortic incompetence, or residual shunt.
Conclusions: The minimally invasive technique appeared to be safe and efficacious for closure of perimembranous ventricular septal defects in the operating room with acceptable short-term outcomes.
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Introduction
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Perimembranous ventricular septal defects (VSD) are among the most common congenital cardiac malformation. Closure is routinely performed with the patient undergoing cardiopulmonary bypass (CPB). Cardiopulmonary bypass and sternotomy are important factors that might lead to increased postoperative morbidity and prolonged hospital stay.
With the recent surge of minimally invasive techniques in adults, a few institutions have attempted to repair ventricular septal defects under endoscopic guidance by placing the patient on CPB through femoral vessels. This technique may injure the femoral vessels and the risk of CPB persists. In addition, this technique cannot be applied in younger patients because of small vessel size. Percutaneous device closure of VSD was reported by many hospitals. However, the aortic valve was easily injured [1] by wire and atrioventricular block was reported [2, 3].
This report describes our initial experience with perventricular device closure of perimembranous VSD without CPB by a subxiphoid minimally invasive incision.
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Patients and Methods
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Study Population
From January 2007 to March 2007, 12 perimembranous VSD patients (Table 1) were closed by this method. These patients consented to have this operation, and they were informed that this was a new operation. The Ethics Committee approved this operation.
The Devices
The devices were made by Shanghai Shape Memory Alloy (Shanghai, China). The devices were constructed from 0.004-inch wire mesh (Nitinol). The wires were laser welded and then braided with heat treatment. The device was woven to form two disks with a connecting waist. Important features of the device are that it is self-expandable, self-centering, and retrievable, has a low profile, and can be delivered through a 7F to 9F sheath. It has a microscrew on one (right or left) disk for attachment to the delivery cable. A Dacron patch (C. R. Bard, Haverhill, Pennsylvania) is sewn inside the disk to decrease shunting through the wire mesh. The device is withdrawn into a loader before introduction into the delivery sheath. For the perventricular approach, however, a simple and short delivery sheath is used because the device can be easily rotated at the time of deployment. The delivery sheath size is dependent on the size of the device. The occluder (Fig 1) is available in sizes ranging from 5 mm to 14 mm, with 2-mm increments. The diameter of the device waist corresponds to the size of the VSD with a 2-mm rim.
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Fig 1. (Top) The occluder included the left and right ventricular discs. (Middle) The right ventricular disc was withdrawn into the loader. (Bottom) Both the left and right ventricular discs were withdrawn into the loader.
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Perventricular Technique
The supine patients were placed under general anesthesia with single-lumen tracheal intubation. Intraoperative transesophageal echocardiography (TEE) was mandatory to reassess the VSD with particular note of the left and right ventricular defect size, and margin adjacent to the aortic valve. A 5-cm incision was made in the subxiphoid, and lower partial sternotomy was performed. The pericardium was suspended and the right ventricular (RV) free wall was exposed. The RV free wall was palpated to locate the area of maximal thrill corresponding to the VSD location. A pursestring suture was placed at this location, and a 16G needle was introduced into the RV cavity within the pursestring. A guidewire was passed through the needle and into the RV cavity. A short introducer sheath (7F to 9F) was fed over the wire and manipulated into the left ventricular (LV) cavity through the VSD under the guidance of TEE (Fig 2). The device (1 to 2 mm larger than the VSD diameter) was advanced inside the short delivery sheath, and the LV disk was deployed first under TEE guidance by retraction of the sheath. Once the LV disk was confirmed by TEE, the RV disk was then deployed by withdrawing the sheath until the device was completely opened (Fig 3). A complete TEE study was performed to confirm device placement and assess residual shunting and aortic incompetence. If TEE examination was satisfactory, the device was released and the sheath was pulled out of the right ventricle. A chest tube was placed in the pericardial cavity. The patients were transported to the intensive care unit.
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Fig 2. The tip of the sheath (short arrow) was manipulated into the left ventricular cavity through the ventricular septal defect (long arrow).
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Transthoracic echocardiography and electrocardiography were performed at 3 months after the procedure.
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Results
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The VSD was successfully closed in the 12 patients. At follow-up of 2 to 4 months, there was no incidence of device embolization, atrioventricular block, new aortic incompetence, tricuspid incompetence, and residual shunt. The procedure duration was 40 to 60 minutes. The 12 patients had less than a 1-day stay in the intensive care unit. The hospital stay was 4 days. A check echocardiogram was performed before discharge in all patients. The 12 patients were given aspirin 100 mg once daily for 3 months. There were no wound complications.
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Comment
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Amin and colleagues [4–6] reported muscular and perventricular device closure of perimembranous VSD in animal models, and Bacha and colleagues [7] reported perventricular device closure of muscular VSD in 6 patients. One of the patients underwent device closure of muscular VSD without CPB by a subxiphoid minimally invasive incision whereas the rest had a standard median sternotomy.
Bacha and coworkers [7] also first reported that 1 patient who had muscular VSD also underwent a similar operation through a subxiphoid minimally invasive incision. This was the first report on a patient undergoing perventricular closure of muscular VSDs without CPB by a subxiphoid minimally invasive incision. To date, there has been no published report on perventricular closure of perimembranous VSD without CPB in patients through a subxiphoid minimally invasive incision. Doctor Li Feng introduced closure of perimembranous VSDs without CPB in patients by a subxiphoid minimally invasive incision in China (personal communication, 2006). The technique was used in the 12 patients with no problems. It showed an excellent result in the short term.
The advantage of the technique is obvious. The learning curve is short. It is easy to manipulate the sheath into the left ventricle through the VSD under the guidance of TEE. The guidewire and sheath is easily kept away from the aortic valve to avoid damaging it. We have not had any new aortic incompetence develop during or after the procedure. New aortic incompetence has occurred occasionally in transcatheter closure of perimembranous ventricular septal defect [1]; this is a serious complication.
It was interesting that we did not have any AV block (including first-, second-, or third-degree block) in operation or follow-up of our patients. We believe that outcome may be due to the direct introduction of the guidewire and sheath into the left ventricle through the VSD without traumatizing the AV node. The wire and sheath easily reach the left ventricle through the defect to avoid damaging the AV node. Atrioventricular block usually occurred in transcatheter closure of perimembranous VSD [2, 3].
This technique uses an occlusion device without the use of radiation. The damage by radiation to the ovary and testicle is definite, especially in children and youths. There is also an added safety element of the procedure being performed in the operating room with the potential for surgical treatment of any complication that may occur. The obvious limitation of this technique, however, is the requirement for an incision as opposed to the percutaneous technique. Nevertheless, we believe that this method is superior to the percutaneous technique.
In summary, we believe perventricular closure of perimembranous VSDs without CPB by a subxiphoid minimally invasive incision is a safe and efficacious technique with superior cosmesis.
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References
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- Holzer R, de Giovanni J, Walsh KP, et al. Transcatheter closure of perimembranous ventricular septal defects using the Amplatzer membranous VSD occluder: immediate and midterm results of an international registry Cathet Cardiovasc Interv 2006;68:620-628.[Medline]
- Fu YC, Bass J, Amin Z, et al. Transcatheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: results of the U.S. phase I trial J Am Coll Cardiol 2006;47:319-325.[Abstract/Free Full Text]
- Sun XJ, Gao W, Zhou AQ, et al. Risk factors for arrhythmia early after transcatheter closure of perimembranous ventricular septal defects Zhonghua Er Ke Za Zhi 2005;43:767-771.[Medline]
- Amin Z, Danford DA, Lof J, Duncan KF, Froeming S. Intraoperative device closure of perimembranous ventricular septal defects without cardiopulmonary bypass: preliminary results with the perventricular technique J Thorac Cardiovasc Surg 2004;127:234-241.[Abstract/Free Full Text]
- Amin Z, Gu X, Berry JM, Titus JL, Gidding SS, Rocchini AP. Perventricular closure of ventricular septal defects without cardiopulmonary bypass Ann Thorac Surg 1999;68:149-153.[Abstract/Free Full Text]
- Amin Z, Berry JM, Foker JE, Rocchini AP, Bass JL. Intraoperative closure of muscular ventricular septal defect in a canine model and application of the technique in a baby J Thorac Cardiovasc Surg 1998;115:1374-1376.[Free Full Text]
- Bacha EA, Cao QL, Starr JP, Waight D, Ebeid MR, Hijazi ZM. Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results J Thorac Cardiovasc Surg 2003;126:1718-1723.[Abstract/Free Full Text]
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Abstract
Introduction
