Ann Thorac Surg 2008;86:146. doi:10.1016/j.athoracsur.2008.04.053
© 2008 The Society of Thoracic Surgeons
Original Articles: Pediatric Cardiac
Invited Commentary
Emile A. Bacha, MD
Department of Cardiac Surgery, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115
(Email: emile.bacha{at}cardio.chboston.org).
The report from West China Hospital [1] is an interesting series of 30 off-pump perventricular transesophageal echocardiographic-guided device closure of membranous ventricular septal defects (VSD) in children ranging from 12 to 36 months of age. A subxiphoid minimally invasive incision was used. Twenty-seven patients (90%) had complete closure, and at 6 months follow-up, complete heart block had not developed in any patient, and 3 patients had mild tricuspid regurgitation. The 3 unsuccessful device attempts were converted to an open-heart approach in the same setting.
This is by far the largest reported series to date, and the lack of serious side effects in the short term is impressive. These excellent results are also strikingly similar to those of another group in China using a similar approach with the same device [2]. The 10% residual VSD rate is concerning at first glance. However, this will undoubtedly improve once the learning-curve is mastered and the indications are refined. In addition, with real-time assessment of procedural efficacy through transesophageal echocardiography, a surgeon can easily convert the procedure to an open-heart approach in the same setting. The perventricular approach also allows avoidance of groin access issues and valve injuries that are due to large sheaths and the crossing of valves.
The facts on the other side of this equation are that elective open-heart repair of membranous VSDs is an extremely safe procedure (0.7% discharge mortality for VSD patch closure in The Society of Thoracic Surgeons' database of 2003 to 2007), and perventricular device closure does not offer greater safety or less complications overall. It does offer less "invasiveness" by avoiding the need for cardiopulmonary bypass and blood transfusions. However, the trade-off is that a metallic device is implanted in the membranous septum with unknown long-term side effects on the aortic and tricuspid valves, left ventricular outflow patency, and risk of heart block. When comparing the perventricular technique to percutaneous device closure, the difference in complete heart block (0% [in both perventricular series] vs at least 5%) is significant [3]. This of course has to be verified by other studies, but one possibility is that the crossing of the VSD and device delivery occurs through an approach that is perpendicular to the septum as opposed to tangential. Percutaneous device closure also showed a disturbing late occurrence of complete heart block, something that is virtually unheard of after patch closure. As the implied mechanism has been "rubbing" of the device against the septal edge or conduction tissue blood supply, it remains to be seen whether this complication will develop with the perventricular approach. It is also worth mentioning two documented cases of complete atrioventricular node recovery after surgical device removal [4].
In summary, perventricular device closure of membranous VSDs carries some definite, but as of yet undefined, potential. Selected groups with expertise should continue to perform and report on VSD device closure. Long-term data is needed, especially in regard to heart block. It is doubtful that this procedure will replace open-heart VSD closure as swiftly as percutaneous atrial septal defect (ASD) device closure replaced open-heart ASD repair [5].
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References
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- Gan C, An Q, Lin K, et al. Perventricular device closure of ventricular septal defects: six months results in 30 young children Ann Thorac Surg 2008;86:142-146.[Abstract/Free Full Text]
- Li F, Chen M, Qiu Z, Lu J, Wu W. A new minimally invasive technique to occlude ventricular septal defect using an occluder device Ann Thorac Surg 2008;85:1067-1071.[Abstract/Free Full Text]
- Butera G, Carminati M, Chessa M, et al. Transcatheter closure of perimembranous ventricular septal defects: early and long-term results J Am Coll Cardiol 2007;50:1189-1195.[Abstract/Free Full Text]
- Ovaert C, Dragulescu A, Sluysmans T, Carminati M, Fraisse A. Early surgical removal of membranous ventricular septal device might allow recovery of atrio-ventricular block Pediatr Cardiol 2007Nov 17 (epub ahead of print).
- Karamlou T, Diggs BS, Ungerleider R, McCrindle BW, Welke K. The rush to atrial septal defect closure; is the introduction of percutaneous closure driving utilization? Ann Thorac Surg (in press).
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Perventricular Device Closure of Ventricular Septal Defects: Six Months Results in 30 Young Children
- Changping Gan, Qi An, Ke Lin, Hong Tang, Raphael C. Lui, Kaiyu Tao, Wencheng Pan, and Yingkang Shi
Ann. Thorac. Surg. 2008 86: 142-146.
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