To the Editor,
The percutaneous closure of ventricular septal defect (VSD) is still not widely used today due to its potential complications (atrioventricular block, valvular heart disease, hemolysis), and technical limitations, particularly, in low-weight patients.1
Devices specifically designed for the closure of perimembranous VSD (pmVSD) have an asymmetric design that conditions implantation via antegrade venous access. Therefore, the standard procedure requires creating an arteriovenous loop across the defect to advance the device until its sequential release from the aorta or the left ventricle. An example of this is the Nit-Occlud Lê VSD-Coil device (PFM Medical, Germany) that has a good safety and efficacy profile.2 However, the creation of the loop can be the cause for transient atrioventricular blocks and hemodynamic instability especially in low-weight patients.3
Also, the use of different unspecific occluders—with good clinical outcomes—for this indication has been described, especially if the defect comes with aneurysmal tissue.4 Thanks to their symmetric design and low profile, some devices can be released from the arterial side (retrograde), thus avoiding the creation of the loop. This simplifies the technique, shortens procedural time, and minimizes the dose radiation received by the patient. Such approach has already been described with good clinical outcomes with a specific design for the closure of the VSD, the Konar-MF (Lifetech, China).5 Given these potential benefits, we decided to start using this technique back in September 2019.
Ever since, transarterial retrograde access has been used in 12 out of every 20 patients treated with the percutaneous or posteroperative closure of VSD. This approach became consolidated during the learning curve and ended up being the approach of choice when dealing with favorable anatomies: non-supracristal perimembranous single defects without coronary leaflet prolapse, at least, 3 mm away from the aortic annular plane of < 6 mm in the right entrance and preferably with aneurysmal tissue. Different occluders with symmetric design were used like the ADO II (patient #4; videos 1 and 2 of the supplementary data), the Piccolo (patient #5; videos 3 and 4 of the supplementary data), the ASO (Abbott) or the Konar-MF (patient #10; videos 5 and 6 of the supplementary data). We included the retrograde use of the ADO device (Abbott) in a patient with postoperative residual VSD without aortic edge with good clinical outcomes.
Procedure was scheduled in all the patients and performed under general anesthesia and with mechanical ventilation. Catheterization of the VSD and the right ventricle was performed with a right coronary artery curve catheter and a 0.035 in hydrophilic guidewire. A Teflon-coated exchange guidewire was placed in the right ventricular apex, 1 catheter carrying the device was mounted on it and moved forward. Sequential release started from the right ventricular apex until contacting the defect. Afterwards, the retention body and disc were released while protected by the catheter across the aortic valvular plane. Monitorization during the procedure was performed under echocardiography (transthoracic if < 10 kg, transesophageal in the remaining cases) and angiography guidance through the carrier catheter. Final hemostasis occurred through manual compression.
The patients’ median age and weight were 4 years (2 months to 38 years) and 22.2 kg (2.7-100), respectively. The largest diameter of the defect estimated through transesophageal or transthoracic echocardiography was 4.5 mm (3 mm to 8.4 mm) while the device waist diameter was 5.5 mm (4 mm to 12 mm). The variety of the devices implanted shows the progression of the technology available during the time of the series, and the lack of devices approved for retrograde use until the arrival of the Konar-MF device.
Procedure was successful in all the patients, and immediate total occlusion was achieved in 10 patients. No acute atrioventricular block events were reported. One embolization of the ADO II device to the pulmonary artery was described in the lowest-weight patient because the defect had been initially underestimated; the defect was recaptured and closed with a larger device. Grade II tricuspid valvular disease was described in the same patient immediately after implantation.
The median x-ray image time was 15.3 min [range, 7-32]. No complications associated with arterial access were reported.
The median of follow-up after the procedure was 20 months (2-67). During this time, 3 deaths that were not associated with the procedure whatsoever (table 1). The remaining patients are still being followed without presence of atrioventricular blocks or valvular heart disease. They all keep the full closure of the defect to this date.
|Patient||Age||Weight (kg)||Underlying heart disease||Indication for closure||Diameter of VSD in the LV Echo (mm)||Qp/Qs ratio||X-ray image time (min)||Success||Immediate complications||Fr||Device||Device waist||Follow-up (m)||Complications at follow-up||Cause of death|
|2||8.4 y||24.5||pmVSD||Echo||7||1.4||11.6||Yes||No||5||ADO II||5||71||No|
|3||4.9 y||20.5||pmVSD||Echo||4.5||1.5||15.3||Yes||No||4||ADO II||4||59||No|
|4||6 m||2.7||pmVSD||Echo||4||3||20.3||Yes||Embolization||4||ADO II||4||12||Death||LTE in syndromic patient (mucopolysaccharidosis)|
|5||8 m||5.7||pmVSD||Postop||3||1.4||17.8||Yes||No||5.5||Piccolo||5||65||Death||Refractory pulmonary hypertension in complex heart disease (Shone complex)|
|7||2 m||6||pmVSD||Postop||3.3||1.4||31.8||Yes||No||4||Piccolo||5||2||Death||Postoperative aortitis|
|8||38 y||100||TOF||Postop||7||1.5||16.4||Yes||No||8||ADO I||12||51||No|
DCRV, double-chambered right ventricle; Echo, repercussion on echocardiography; Fr, French; kg, kilogram; LTE, limitation of therapeutic effort; LV, left ventricle; m, months; min, minutes; mm, millimeters; pmVSD, perimembranous ventricular septal defect; Postop, postoperative; Qp/Qs ratio, pulmonary flow/systemic flow; TOF, tetralogy of Fallot; VSD, ventricular septal defect; y, years.
This is the first case series ever conducted in Spain of closure of pmVSD via retrograde arterial access with a high rate of success and a low rate of complications.
Different unspecific devices for the closure of pmVSD with symme-tric design (ADO II or Piccolo) or else the new Konar-MF device (figure 1)—specifically approved for this procedure —can be implanted via retrograde arterial access, which simplifies the routine closure technique making it feasible for low-weight children in whom the creation of an arteriovenous loops is associated with a higher risk of hemodynamic instability or transient atrioventricular block. Also, the low profile of the device does not increase the risk of damage to the femoral arterial access compared to the traditional technique. Therefore, we propose this therapeutic alternative in selected patients.
A. Rasines Rodríguez, and M. M. Aristoy Zabaleta: data curation, analysis, bibliographic search, and drafting of the manuscript. C. Abelleira Pardeiro: original idea, involved with the patient healthcare process, work supervision, data curation, analysis, and drafting of the manuscript. E. J. Balbacid Domingo: work creation and supervision, and directly involved with the patient’s healthcare process. S. Jiménez Valero, and F. Gutiérrez-Larraya Aguado: patient care, and critical review of the manuscript. All the authors reviewed and approved the manuscript final version.
CONFLICTS OF INTEREST
1. Ghosh S, Mukherji A, Chattopadhyay A. Percutaneous closure of moderate to large perimembranous ventricular septal defect in small children using left ventricular mid-cavity approach. Indian Heart J. 2020;72:570-575.
2. Solana-Gracia R, Mendoza Soto A, Carrasco Moreno J, et al. Registro español de cierre percutáneo de comunicación interventricular con dispositivo NitOcclud Lê VSD-Coil. Experiencia tras más de 100 implantes. Rev Esp Cardiol. 2021;74:591-601.
3. Carminati M, Butera G, Chessa M, et al. Transcatheter closure of congenital ventricular septal defects: results of the European Registry. Eur Heart J. 2007;28:2361-2368.
4. Cinteza˘ E, Butera G. Complex ventricular septal defects. Update on percutaneous closure. Rom J Morphol Embryol. 2016;57:1195-1205.
5. Haddad R, Daou L, Saliba Z. Percutaneous closure of restrictive‐type perimembranous ventricular septal defect using the new KONAR multifunctional occluder: Midterm outcomes of the first middle‐eastern experience. Catheter Cardiovasc Interv. 2019;96:E295-E302.
* Corresponding author.
E-mail address: email@example.com (A. Rasines Rodríguez).