Transcatheter Closure of VSD: What can be safely done?

1. Jonas D. Del Rosario, MD, FPCC Clinical Associate Professor UP College of Medicine Transcatheter Closure of VSD:What can be safely done?

2. No disclosures

3. First DO NO HARM

4. Objectives • What types of VSD are amenable for catheter closure at this time • How to select and screen patients who are amenable for catheter closure of VSD • Concerns/Complications • Present our limited experience with the use of VSD coil in the Philippines

5. Ventricular Septal Defect • Most common congenital cardiac malformation • Surgery is the standard method for closure of VSD • Mortality rate in high volume centers is less than 0.6% to 1.8% • Complication < 1% • Complete heart block is less than 1%

6. VSD Closure with PFM VSD Coils

8. Transcatheter closure of VSD (TCCVSD) • Remains to be the most challenging interventional procedure in CHD • Various devices have been used with a high degree of effectiveness to primarily close muscular and perimembranous VSD

9. Advantages of TCC of VSD • Avoids median sternotomy scar • Avoids cardiopulmonary bypass • Shorter hospital stay • Shorter recovery period

10. Indication for Closure of VSD • Hemodynamically significant Qp:Qs > 1.5 • LA or LV enlargement • Cardiomegaly on CXR • Failure to Thrive • Previous episode of Infective Endocarditis

11. Soft Indications for VSDDeveloped since catheter closure • Better psychosocial impact on patient • Avoid the inherent problems related to stigma of having a heart defect • Employability • Health Insurance • Heavy vehicle license • Sports participation (as a professional)

12. Concerns/Complications • Complexity of procedure • Steep Learning Curve • Applicability in selected group • Proximity of aortic and tricuspid valve • Conduction system (arrhythmias, heart block) • Residual shunt with risk of infective endocarditis • Mechanical haemolysis • Embolization

13. Proper selection of patients is the KEY.

14. What Is Not Amenable For TCC • AV Canal Type (Inlet) • Large Perimembranous VSD(Unrestrictive) • Subpulmonic VSD • Multiple (Swiss Cheese) VSDs • VSD as a component of a more complex lesion

15. Amplatzer Muscular VSD occluder

16. Muscular VSD Device

17. Anterior Muscular VSD device

18. Amplatzer PM VSD Occluder (AVSO) • First device specifically designed for membranous VSD • First reported by Hijazi et al 2002 and Thanopoulos in 2003

19. Perimembranous VSD device

20. Amplatzer PM VSD occluder (AVSO) • Became the most popular device to close VSDs worldwide with good short and medium term outcome • Occurrence of complete heart block in an unpredictable manner even after years post-implantation has currently tempered the enthusiasm of the interventional community (Incidence 1-5%)

21. Heart Block of AVSO • Rim of the VSD closed by AVSO remains under continuous pressure due to the stenting philosophy of this device • This can cause trauma to the neighboring conduction system

22. What Type of Can Be Safely Occluded Muscular VSD Midmuscular/Apical Perimembranous VSD Restrictive Ventricular Septal Aneurysm VSD rim > 3mm from aortic Valve Defect is <6mm from RV side Presents like a “FUNNEL”

23. The PFM VSD Coil • Novel attachment mechanism • Stiff distal loops, covered • with polyester filaments 5.5F delivery catheter; Distal Coil Diameter: 8,10,12,14 mm

24. Nit Occlud Lê VSD – Deutsche Studie 4 Zentren 35 Fälle eine Heilbehandlung (Köln) Venezuela Dr. Borges 12 Patienten Vietnam Dr. Trieu Dr. Nhan Dr. Huan Dr. Hieu Dr. Binh 35 Patienten Brasilien Dr. Pedra Dr. Chamie Dr. Simoes Dr. Rossi 28 Patienten Thailand Dr. Kritvikrom 14 Patienten Malaysia Dr. Wong Dr. Samion 6 Patienten Argentinien Dr. Granja Dr. Peirone 4 Patienten Ägypten Dr. Sayhed 3 Patienten Saudi Arabien Dr. Galal Dr. Ekram 9 Patienten

25. VSD Coil (Nit-Occlud Le VSD Coil) • Conical-shaped nitinol coil • More flexible, softer and conforms to the shape of VSD • Less traumatic • Used for: • Perimembranous VSD with aneurysmal pouch and muscular VSD • Muscular VSD

26. Shapes of membranous and muscular VSD Courtesy Dr. L. Simoes

27. VSD with VSA formation

28. VSD with VSA formation

30. Occlusion of VSD using the PFM VSD Coil

31. International Experience with the PFM VSD Coil 117 Patients with restrictive VSD Perim. VSD (n=97) Musc. VSD (n=10) Subpulm. VSD (n=10)

32. International Experience with the PFM VSD Coil

33. International Experience with the PFM VSD Coil

34. International Experience with the PFM VSD Coil

35. International Experience with the PFM VSD Coil Device Displacement: none Device Fracture: none Device Embolization: 2 (transcath. removal within 3 hours) AI: n = 2 (I-II°) TR: n = 2 (II°) Hemolysis: n = 5 4 transient 1 severe, device surgically removed Problems of conduction system: none!

36. Occlusion of VSD using the PFM VSD Coil • Coil Selection • Distal coil diameter is • at least double the minimal diameter • (right ventricular opening) • equal or 1-2mm larger than left ventricular • diameter of VSD. Prox. Loop Diameter: 6 mm 6 mm 6 mm 8 mm Distal Loop Diameter: 8 mm 10 mm 12 mm 14 mm

37. VSD Coil (UP-PGH) experience • 5 patients • 3y – 29 y • VSD with Ventricular septal aneurysm • 1st case was done 3 years ago • Last 4 cases done 1 year ago • Total occlusion after 1 month • No incidence of heart block, CVA, IE and death

38. The implantation procedure Transvenous implantation Guidance by TOE or TTE

43. PDA device to close VSDs? • Perimembranous VSD which are “conical” (like a PDA type A) • Distance from the aortic valve is >4mm • Amplatz Duct Occluder Nguyen LanHieu, MD, PhD • Hanoi Medical University-Vietnam Heart Institute • Performed in some patients in Heart Center

44. Pm VSD (conical)

45. VSD (conical)