Hybrid Muscular VSD Closure in Small Weight Children

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1 Hybrid Muscular VSD Closure in Small Weight Children Shakeel A Qureshi, on behalf of: John P. Cheatham, MD George H. Dunlap Endowed Chair in Interventional Cardiology Director Cardiac Catheterization & Interventions Co-Director, The Heart Nationwide Children s Hospital The Ohio State University Columbus, Ohio, USA

2 Special thanks to: Ziyad M. Hijazi, MD & Qi-Ling Cao, MD Rush Medical Center, Chicago

3 Muscular VSD A challenge to all who attempt to treat Membranous VSD Still best closed by conventional surgery If in cath lab, percutaneous is preferred Zahid Amin experimenting with Hybrid China reports success as well (30 pts)

4 Surgical Closure of muscular VSDs Can be a significant surgical challenge Occasionally need RV incision for better visualization Rarely may need LV incision When multiple, need for PA band Morbidity & mortality issues & residual defect(s) A less-invasive, transcatheter approach may offer certain advantages

5 Catheter Closure of Muscular VSD Amplatzer Muscular VSD Device Nitinol 6-8Fr 4-18mm Waist 7mm long LV/RV discs 4mm rim larger than waist

6 Catheter Closure of Muscular VSD General anesthesia vs conscious sedation TEE vs TTE vs ICE Routine cardiac catheterization Balloon sizing - optional Arteriovenous Loop vs Retrograde only Device deployment Angiography

7

8 Catheter closure of muscular VSD N=80 Age 7.3±13.2 ( yr) Weight 22.5±30.7 ( kg) Gender 39M/41F Cardiac History CHF 36.3% Arrhythmias 11.3% Recurrent resp. Inf. 3.8% FFT 30% Previous cardiac surgery 42.5%

9 Catheter closure of muscular VSD N=80 TTE Single VSD 57.9% Two or more 42.1% Primary VSD size 7.1±2.4 (3-17 mm) Secondary VSD size 4.7±2.9 (1-18 mm) Location Anterior 32.5% Posterior 11.3% Apical 33.8% Mid-muscular 56.3%

10 Catheter closure of muscular VSD N=80 Technical Failure Unable to cross the defect 1 Defect too big 2 Patient developed hypotension & bradycardia 1 Device embolized to LV - surgical removal 1 Catheter dislodgment, blood loss, death 1 Cardiac perforation, death 1 ***Most SAE related to size of patient < 5.2Kg

11 8mm Amplatzer Muscular VSD Occluder & Coil PDA in a 3.5 Kg infant

12 Multiple muscular VSDs 2 infants with Swiss cheese VSDs Top Panels: 11 mo/old with 8mm, 6mm, & 8mm AMVSDO Left Panel: 2 y/o with 6mm & 8mm AMVSDO. Also has 3 ASOs: 11,9,& 6mm

13 Transcatheter device closure of congenital muscular VSD An attractive alternative to surgery However, it is difficult: in small infants children with poor vascular access in patients with unusual septal planes

14 Hybrid perventricular closure Requires collaboration with a surgeon No limit in size of patient Little hemodynamic compromise

15 Site of Perventricular Implant Operating room vs Cath lab vs Hybrid suite

16 We started in the same space in Orlando The Operating Room became the Cath Lab for 4 months A portable C-Arm, TEE, and sterile room is just fine

17 Hybrid Cardiac Catheterization Suites for CHD: NCH: June, 2004

18 Hybrid Cardiac Operative Suite for CHD NCH November, 2007

19 Preparing Perventricular Access

20 Using TEE Guidance

21 Technique in The Operating Room or Hybrid Suite Sterile environment TEE guidance IS ESSENTIAL Sternotomy vs subxiphoid incision Determine the best course for the puncture 5-0 polypropylene purse string suture Puncture RV free wall using an angled 18 G needle Cross the VSD with a angled glide wire to LV Pass a short sheath over the wire to LV mid cavity

22 Technique Measure the length of the short sheath Make a mark on the cable Pass the short sheath over the wire to LV mid cavity De-air the sheath

23 Technique Attach the device to the cable Load it under saline seal Advance the cable until it reaches the tip of the sheath (mark)! TEE monitoring is essential during this step Deploy device & assess result

24 Technique in The Cath Lab or Hybrid Suite TEE guidance essential Access femoral artery & vein Complete hemodynamic assessment Angiogram in the LV to profile VSD Sternotomy vs subxiphoid incision Determine the best course for the puncture 5-0 polypropylene purse string suture Puncture RV free wall using a 18 G needle Cross the VSD with a guide wire to LV If VSD can t be crossed via RV free wall

25 Technique in The Cath Lab or Hybrid Suite Cross VSD percutaneously via femoral artery - LV under fluoroscopy Advance guidewire to PA Snare wire from RV free wall puncture under fluoroscopy Exteriorize wire out of the free wall Arteriovenous-RV free wall loop Advance short sheath over this wire to a position in LV Remainder of steps is similar to OR technique

26 5 month with multiple VSD s: procedure in cath lab 2 devices implanted

27 Courtesy University of Chicago

28 U of Chicago/Rush Clinical Experience N=11 Isolated MVSD s: 3 infants; subxiphoid incision, no CPB MVSD s + additional lesions Coarctation: 3 (repair VSD beating heart, then coarct) PAB & Swiss cheese VSD s: 3 (one per-atrial ASD closure) DORV/subaortic VSD/Swiss cheese, PS: 1 DORV/TGA/hypoplastic LV/MVSD: 1

29 5 month old weighing 7kg DORV, subaortic VSD, PS, apical VSD s A B C D Discharged day 6

30 4 month old weighing 4 kg Large anterior muscular VSD & aneurysmal septum with ASD

31 Discharged day 3

32 1 Year Follow Up (n=11) No residual flow No significant TR No arrhythmias

33 What Others Report Gan, et al, Perventicular device closure of muscular VSD on beating hearts: initial experience in 8 children; JTCVS, April defects in 8 children: 14/15 closed with a device No blood required, no residual shunts, no mortality Diab, et al, Perventricular closure of muscular VSD: How to do it?; Ann Ped Card, Jan-June Pedra, et al, Perventricular device closure of muscular VSD; Expert review Cardiovasc Ther, May Diab, et al, Device closure of muscular VSD in infants less than 1 year of age using Amplatzer devices; CCI, 70, /19 had perventricular closure and 11/19 had percutaneous closure No residual defects, no mortality Holzer, et al, Device closure of muscular VSD using the Amplatzer MVSDO-immediate and mid-tem results of a US registry; JACC, 43, pts with 83 procedures: 6/75 had perventricular closure with no residual flow and no mortality

34 NCH Experience Perventricular muscular VSD closure (9) 4 ½ y/o after PA band: 8 & 12mm Amplatzer MVSD Occluders delivered 3 week old prior to complete repair membranous VSD, ASD, & IAA: 4mm AMVSDO placed for apical VSD 7 week old near membranous VSD - failed secondary to device length being too long with interference MV/TV 5 y/o with large defect - failed 18mm Occluder too small for defect & no Post Infarct MVSDO available 2 week old: 6mm AMVSDO during membranous VSD and IAA repair 2 mo old with CHF and FTT: 10mm AMVSDO implanted 1 week old with CHF: 12mm AMVSDO implanted 5 week old with CHF: 10mm AMVSDO implanted 7 mo old with CHF: 18mm AMVSDO implanted in apex

35 2 mo/old with large mid muscular VSD Pushing on RV free wall

36 10 mm AMVSD Occluder placed

37 4 y/o weighing 7.6 Kg with multiple muscular VSDs, PA band, & R-BTS: Perventricular Delivery of 12mm & 8mm AMVSDO

38 2 week old: 6mm AMVSDO before PmVSD & IAA

39 After 3 months, residual CoA had ballooning

40 Conclusions Perventricular closure for muscular VSD is an effective technique requiring collaboration between surgeon & interventionalist Ideal technique for small infants (<5Kg & maybe <10Kg) and those with complex anatomy or patients with other CHD requiring concomitant surgical repair An experienced echocardiographer is a must The time required for closure is much shorter and with less hemodynamic compromise compared with percutaneous technique

41 It Takes Collaboration

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