Percutaneous VSD closure
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1 Percutaneous VSD closure Gianfranco Butera San Donato Milanese - Italy
2 Patients selection Pts having hemodynamically significant VSD Left ventricular enlargement (left ventricular overload),defined as a LVEDD > +2 SD above the mean for the patient s age.. Hystory of bacterial endocarditis Clinical evaluation, EKG, Chest-x-ray, echo Exclusion criteria: Body weight < 5-6 Kg for mvsd and <8-10 kg for pmvsd
3 Which patients with congenital VSD are not suitable to percutaneous closure? Exclusion criteria: Supracrystal VSD Malalignement VSD Associated significant aortic regurgitation Prolapse of aortic cusp Sub-aortic stenosis Sub-pulmonary stenosis (RV mid ventricular stenosis) Eisenmenger syndrome High pulmonary pressures (PAR > 2/3 SAR)
4 VSD
5 VSD
6 Muscular VSD Pre-procedural Echocardiographic evaluation (TTE/TEE) Size (measure in different views) Number (single/multiple) Location (apical/mid muscular/high muscular) Associated defects (ASD/pulmonary stenosis/aortic coarctation/others) Contra-indication to percutaneous closure
7 Muscular VSD Procedural Echocardiographic evaluation (TEE) Integrate data from fluoroscopy and EKG Analysis of VSD (Size/Number/Location/Associated defects Contra-indication to percutaneous closure) Check position of : Guide wire (TV, AoV) Ventricular function during manoeuvres Long-sheath (MV, free LV wall, AoV, TV)
8 Muscular VSD Usually it is quite easy to analyse the margins and measure the size of the defect Margins are usually well seen Measure of the defect in 2D and with color (measure at the PISA ) Policlinico San Donato IRCCS
9 Muscular VSD Policlinico San Donato IRCCS
10 Muscular VSD Policlinico San Donato IRCCS
11 Procedure protocol General anesthesia Full heparinization Arterial and venous access Basal hemodynamics Assessment of VSD size and location Fluoro and TEE monitoring
12 Amplatzer muscular VSD occluder
13 Amplatzer muscular VSD occluder
14 Amplatzer muscular VSD occluder
15
16 Multiple Muscular VSD s Implantation of 2 devices
17 Retrograde closure of high muscular VSD
18 Retrograde closure of high muscular VSD
19 Retrograde closure of high muscular VSD
20 Retrograde closure of high muscular VSD
21 Retrograde closure of high muscular VSD (interrupted IVC and azygos continuation)
22 Retrograde closure of high muscular VSD (interrupted IVC and azygos continuation)
23 Complications Device entangled in the tricuspid valve Sometimes worsening of TR during f-up
24 Residual post-surgery VSD
25 Residual post-surgical VSD
26 Residual post-surgical VSD xxxxxxxx
27 Residual post-surgical VSD
28 Residual post-surgical VSD
29 Residual post-surgical VSD
30 Non standard procedure (aortic approach) Istituto Policlinico San Donato
31 Non standard procedure (aortic approach) Istituto Policlinico San Donato
32 Residual post-surgical VSD
33 Residual post-surgical VSD Balloon sizing of the defect - exact site, size, and position of the residual shunt - not stop-flow in most of the cases but a pull-through TEE and angiography It is essential to have expert TEE guidance Aortic retrograde approach - easier in these cases. -anterograde approach: it can be difficult to advance the sheath tip to the LV apex (surgical patches?) - there is less space in the sub-aortic region to deploy the LV disc and increased risk of complications. - if the LV disc is deployed in the ascending aorta, it is more difficult to retrieve it back in the sheath, if required, with increased risk of damaging the aortic valve. Limitation subjects who may accommodate the use of a 8Fr long-sheath in the femoral artery.
34 Amplatzer membranous VSD occluder eccentric device
35 Amplatzer membranous VSD occluder eccentric device
36 Amplatzer membranous VSD occluder eccentric device
37 Perimembranous VSD Pre-procedural Echocardiographic evaluation (TTE) Size (measure in different views) Number (single/multiple) Extension (inlet/trabecular/outlet) Aneurysm/Pouches from the TV/ septal L of the TV Associated defects (ASD/pulmonary stenosis/aortic coarctation/others) Contra-indication to percutaneous closure
38 Perimembranous VSD Procedural Echocardiographic evaluation (TEE) Integrate data from fluoroscopy, EKG Analysis of VSD (Size/Number/Location/Aneurysm/Associated defects Contra-indication to percutaneous closure) Check position of : Guide wire (TV, AoV) Ventricular function during manouevres Long-sheath (MV, free LV wall, AoV,TV) Policlinico San Donato IRCCS
39 Perimembranous VSD Echocardiographic evaluation Policlinico San Donato IRCCS
40 Perimembranous VSD Echocardiographic evaluation Policlinico San Donato IRCCS
41 Perimembranous VSD Echocardiographic evaluation Policlinico San Donato IRCCS
42 Perimembranous VSD Procedural Echocardiographic evaluation (TEE) Check interatrial septum, direction of shunting on PFO/ASD Check tricuspid valve Check device deployement: LV disk (MV, free LV wall, IVS, Ao valve) Connecting waist RV disk (IVS, TV) Policlinico San Donato IRCCS
43 Perimembranous VSD Procedural Echocardiographic evaluation (TEE) Check device position: malposition? embolization? Pericardial effusion? Regurgitation of AoV,MV,TV? Policlinico San Donato IRCCS
44 Perimembranous VSD Closure with eccentric device
45 Perimembranous VSD
46 Perimembranous VSD
47 Perimembranous VSD
48 Perimembranous VSD with septal aneurysm
49 Multiple Perimembranous VSD with septal aneurysm
50 Multiple Perimembranous VSD with septal aneurysm
51 Multiple Perimembranous VSD with septal aneurysm
52 Perimembranous VSD with septal aneurysm Closure with Muscular VSD occluder
53 Perim.VSD + ASD + PDA
54 Amplatzer perimembranous VSD occluder Tips, Tricks, Hints and Pitfalls Difficulties in advancing the sheath over the AV circuit: start all over again Desaturation when the sheath is in place: R-to-L shunt through the PFO/ASD due to functional tricuspid stenosis Retrograde closure from the the aortic side Difficulties in placing the sheath towards the LV apex: open the device from the aorta
55 Complete -AVB Large variability in Clinical presentation (asymptomatic-mild symptomssyncope-sudden death) Timing (up to 2 years after procedure) Answer to steroids Istituto Policlinico San Donato
56 Perimembranous VSD and cav block: possible mechanisms and risk factors Early Heart block Trauma/edema from catheter manipulation and/or device Inflammatory reaction to device Down s Syndrome Late Heart block Trauma from continuing expansion of an oversized device fibrosis Down s Syndrome
57 Perimembranous VSD
58 Oversizing
59 Oversizing
60 Perimembranous VSD
61 Perimembranous VSD
62 Perimembranous VSD Transcatheter closure of congenital ventricular septal defects in adults: Mid-term results and complications. Int J Cardiol 2008 Jan 28 M. Chessa, G. Butera, M. Carminati. 0% occurrence of cavb
63 Perimembranous VSD 0% occurrence of cavb in children > 5 years old
64 Perimembranous VSD
65 Closure of PMVSDs Tomorrow
66 AMPLATZER Membranous VSD Occluder 2 Minimizes Pressure on the Septal Tissue The dual-layer waist is engineered to impart minimal radial pressure against the defect while providing stability 3mm waist length reduces clamp force on the ventricular septum
67
68 Thank you for your attention HSD - PEDIATRIC CARDIOLOGY
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