Surgery for doubly committed ventricular septal defects.

OBJECTIVES: Doubly committed ventricular septal defects (VSDs) account for up to almost one-third of isolated ventricular septal defects in Asian countries, compared with only 1/20th in western populations. In our surgical experience, this type of defect accounted for almost three-quarters of our practice. To date, patch closure has been considered the gold standard for surgical treatment of these lesions. Our objectives are to evaluate the indications and examine the outcomes of surgery for doubly committed VSDs. METHODS: Between October 2013, when our service of paediatric cardiac surgery was opened, and December 2014, 24 patients were referred for surgical closure of VSDs. Among them, 17 patients (71%), with the median age of 6 years, ranging from 2 to 9 years, and with a median body weight of 19 kg, ranging from 11 to 56 kg, underwent surgical repair for doubly committed defects. In terms of size, the defect was considered moderate in 4 and large in 13. Aortic valvular regurgitation (AoVR) was present in 11 patients (65%) preoperatively, with associated malformations found in 14 (82%), with 5 patients (29%) having two or more associated defects. RESULTS: After surgery, there was trivial residual shunting in 2 patients (12%). AoVR persisted in 6 (35%), reducing to trivial in 5 (29%) and mild in 1 (6%). Mean stays in the intensive care unit and hospital were 2.6 ± 1.2 days, ranging from 2 to 7 days, and 6.8 ± 0.8 days, ranging from 6 to 9 days, respectively. The mean follow-up was 14 ± 4 months, ranging from 6 to 20 months, with no early or late deaths and without clinical deterioration. CONCLUSIONS: The incidence of doubly committed lesions is high in our experience, frequently associated with AoVR and other associated malformation. Early detection is crucial to prevent further progression of the disease. Patch closure remains the gold standard in management, not least since it allows simultaneous repair of associated intracardiac defects.

The results of transcatheter closure of VSD using Amplatzer® device and Nit Occlud® Lê coil.

OBJECTIVE: We retrospectively reviewed the result of patients who underwent transcatheter closure of ventricular septal defect (VSD) using Amplatzer® Perimembranous or Amplatzer® muscular VSD device (the Amplatzer® group) and Nit Occlud® Lê VSD Coil (the Pfm group). BACKGROUND: Perimembranous type (PmVSD) and doubly committed subarterial (DCSA) VSD were the major isolated congenital heart defects in Thai children. Transcatheter device closure technique for both types of VSD has emerged as an alternative treatment to surgery. METHODS: Retrospectively, data was reviewed between 2003 and 2009. RESULTS: 116 patients were enrolled. Device or coil was successfully implanted in 94%. Complete closure at 24 hr is slightly higher in the Amplatzer® group. The average size of VSD in the Amplatzer® group was larger than the Pfm group (P = 0.001). The Pfm coil was primarily deployed in DCSA VSD when compared with the Amplatzer® group (P < 0.01). At 6 months follow-up the residual shunt was comparable (P = 0.054). There was only one transient AV block (AVB) in the Pfm group and 5 AVB in the Amplatzer® group. Four pacemakers were placed in the Amplatzer® group. CONCLUSIONS: Transcatheter closure of VSD in both Pm VSD and DCSA can be achieved by using either of the device. The Amplatzer® VSD device had the advantage of closure of larger defects with immediate less residual shunt but appeared to have a significant number of 3° AVB, which required pacemaker implantation. The Nit Occlud® Lê VSD Coil had the advantage of closure of both types of defects, in particular DCSA VSD with only small residual shunt.

Real-time 3-dimensional echocardiography for follow-up of Waterston shunt.

A 37-year-old man presented with Eisenmenger's reaction. He had progressive cyanosis and signs of right-sided heart failure. In early childhood he was palliated with a Waterston shunt for cyanotic congenital heart disease. Two-dimensional echocardiography provided only a rudimentary view of his heart's anatomy and hemodynamics. Real-time three-dimensional echocardiography (RT3DE) was superior in visualizing both the size and the shape of the large shunt. RT3DE easily identifies and quantifies a key pathogenic factor for pulmonary hypertension with irreversible vascular damage in such patients. If applied early, RT3DE may prove to be a valuable follow-up tool.

Noninvasive follow-up of complications after the Takeuchi operation.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare lesion. Untreated, up to 90% of patients die before 1 year of age. The Takeuchi operation and direct coronary artery reimplantation have resulted in low mortality rates and excellent functional outcome. We present the case of a 6-year-old girl with impaired exercise tolerance in whom anomalous origin of the left coronary artery from the pulmonary artery was detected. A Takeuchi operation was performed. Routine follow-up was successfully done by echocardiography. The postoperative anatomy was visualized in detail, including a baffle-to-pulmonary artery fistula and a coronary artery stenosis. Potentially, given current echocardiographic technology in the hands of experienced operators, routine follow-up may be done noninvasively, leaving angiography for nonroutine indications.

Early cardiac perforation after atrial septal defect closure with the Amplatzer septal occluder.

We report a case of aortic perforation after transcatheter closure of an atrial septal defect by an Amplatzer septal occluder. During emergency surgery, perforations of the dome of the right atrium and the noncoronary sinus of Valsalva of the aorta were repaired. Atrial septal defect was primarily closed. A short anterosuperior rim should be considered a risk factor for aortic perforation in transcatheter atrial septal defect closure.

Percutaneous closure of congenital and acquired ventricular septal defects--considerations on selection of the occlusion device.

Nonsurgical closure of congenital and acquired ventricular septal defects (VSD) has become increasingly acceptable with the availability of various occlusion systems that allow percutaneous treatment of muscular and membranous defects. This study describes a series of 12 patients (0.2-74-years-old) who underwent defect closure with six different occlusion systems. Device selection according to anatomy and outcome is highlighted. Seven VSDs were located in the membranous part of the septum, five in the mid-muscular septum. Complex heart lesions were present in five postmyocardial infarction VSD in one and residual postsurgical defects in three patients. The size of the VSD ranged from 2.6 to 10 mm. The applied devices were: Amplatzer muscular VSD occluder (n=4), Amplatzer septal occluder (n=2), Amplatzer duct occluder (n=1), Amplatzer membranous VSD occluder (n=2), Nit-Occlud coil (n=2), and Cook PDA coil (n=1). The devices were implanted successfully in nine patients. There was complete VSD closure in eight patients within the first 24 hours. In one patient, a trivial residual shunt disappeared at 6 months follow-up. Because of device instability, two occluders were removed during catheterization. In two other cases, tricuspid valve tissue was entrapped in the occluder and had to be removed surgically, one of them during the consecutive Rastelli operation. Neither significant arrhythmia, nor thromboembolism or hemolysis occurred in out patients during follow-up. Transcatheter closure of VSD is an attractive alternative to surgery. In complex congenital heart disease, surgical-interventional hybrid therapy may improve morbidity and total outcome. The recently developed Amplatzer VSD devices allow closure of muscular and membranous VSDs. Implantation and short-term follow-up are superior to the formerly used devices. Long-term effects have to be evaluated in further studies.

Duct-Occlud for Occlusion of Patent Ductus Arteriosus.

The Duct-Occlud Occlusion System (ATG Co., Malta, Europe) is the only coil-type device that has been specifically designed to close the patent ductus arteriosus (PDA). The Duct-Occlud coil has no Dacron feathers. Occlusion of the PDA is achieved by precise positioning and implantation of a large number of densely packed coils with configuration appropriate for the PDA. A principle feature of the delivery system is retrievability, which facilitates both repositioning of a suboptimally placed device and exchange for a larger or more appropriate device. Standard and reinforced devices are available for closure of PDA with minimum diameter up to 4 mm. Clinical studies have demonstrated device safety and efficacy.