Transthoracic device closure of perimembranous ventricular septal defect via a small left intercostal incision in children.

Background: In children with perimembranous ventricular septal defect, surgical repair requires sternotomy and leaves unsightly scars, which can trigger long-term physical and psychological distress. However, transcatheter device closure is limited by vascular diameter, radiographic exposure, and expensive DSA equipment. We used an ultra-small left intercostal incision for transthoracic device closure to avoid the above problems and investigated its safety and feasibility by comparing it with surgical repair. Methods: This study enrolled 358 children with perimembranous ventricular septal defect. Among them, 152 patients were treated by surgical closure and 206 by transthoracic device closure via an ultra-small left intercostal incision. Perioperative clinical data and postoperative follow-up results were collected and analyzed retrospectively. Results: The success rate was similar (P = 0.265) in the two groups: 203/206 patients in the device group vs. 152/152 patients in the surgical group. The operative time, intensive care unit time, mechanical ventilation time, and postoperative hospital stay were significantly shorter in the device group than in the surgical group. Although the incision length of the device group (1.1 ± 0.2 cm) was significant shorter (P < 0.001) than that of the surgical group (6.7 ± 1.5 cm), there was no difference in hospitalization costs between the two groups (P = 0.099). Except for small residual shunt (16/206 vs. 3/152, P = 0.017), the incidence of complications in the device group was lower or equal to that in the surgical group, and all small residual shunt disappeared during follow-up. There was no thoracic deformity in the device group, compared with 11 cases in the surgery group during follow-up (P < 0.001). Conclusions: Transthoracic device closure via an ultra-small left intercostal incision under transesophageal echocardiography guidance is safe and feasible. With appropriate indications, it can be a suitable alternative to surgical closure for treating perimembranous ventricular septal defect in children.

A comparison of the changes in serum lactate between surgical repair and transthoracic device closure of ventricular septal defects in pediatric patients.

Objective: The purpose of this study was to compare the changes in serum lactate between surgical repair and transthoracic device closure of ventricular septal defects (VSDs) in pediatric patients. Methods: This study was a retrospective analysis, and 314 pediatric patients with simple VSD from October 2019 to October 2021 were selected. The patients were divided into the S group (surgical repair) and the D group (transthoracic device closure). The serum lactate value at ICU admission and 6 h after operation, as well as the highest serum lactate value were collected, and the 6-h serum lactate clearance rate was calculated. Result: Through propensity score matching, 43 pairs of cases were successfully matched. Compared with the S group, the D group had a shorter operation duration, ventilation duration, and ICU duration, as well as a lower drainage volume and total hospitalization cost. There was no significant difference between the two groups in the initial and highest serum lactate values after VSD closure, while the 6-h serum lactate value in the D group was significantly lower than that in the S group, and the 6-h serum lactate clearance rate in the D group was five times faster than that in the S group. In addition, the 6-h serum lactate clearance rate in the S group was mainly related to the operation time, CPB time, and ventilation time, while the 6-h serum lactate clearance rate in the D group was only related to the operation time. Conclusion: The initial and highest serum lactate levels were not significantly different between surgical repair and transthoracic device closure of VSD, but the 6-h serum lactate clearance rate of device closure was five times faster than that of surgical repair.

Parents' knowledge and attitudes regarding transthoracic device closure of VSD in children: a cross-sectional study.

OBJECTIVES: This study aimed to identify Chinese parents' knowledge and attitudes toward transthoracic device closure of ventricular septal defect (VSD). METHODS: This cross-sectional study collected data on a total of 203 Chinese parents of patients with VSD were included, and an author-designed three-page questionnaire was used. RESULTS: A total of 73.9% of the parents had heard of transthoracic device closure of VSD; however, they lacked detailed knowledge. 88.2% parents expressed their willingness to undergo this procedure. Although there was no significant correlation between knowledge about the occluder material and acceptance of the method, knowledge of other information was significantly related to willingness to undergo the procedure. Some parents expressed some concerns and high expectations, but the postoperative risk reduced their desire for accepting the procedure. This study also found that most parents did not have a detailed understanding of such procedure. CONCLUSION: Parents of patients with VSD in China need continued education regarding transthoracic device closure of VSD, especially in terms of its benefits and limited postoperative complications. In addition, it is essential to reduce the cost of this procedure to promote its development and application.

Transthoracic closure of ventricular septal defects guided by transesophageal echocardiography.

BACKGROUND: This study aims to investigate the effectiveness and safety of transthoracic closure of ventricular septal defects totally guided by transesophageal echocardiography. METHODS: A total of 119 patients (62 males, 57 females; mean age 2.1±5.2 years; range, 11 months to 50 years) who underwent transthoracic closure of ventricular septal defects in our center between April 2017 and November 2018 were included. All patients were evaluated in terms of the diameter and morphological features of ventricular septal defects via transesophageal echocardiography. During the procedure, transthoracic echocardiography was used as the only guiding tool for occluder implantation. RESULTS: Of the patients, 116 underwent successful transthoracic device closure procedure. Two patients were switched to surgical repair due to new-onset aortic regurgitation in one patient and severe arrhythmias after device release in the other patient. One patient underwent a second operation for occluder migration during the hospital stay. In the first attempt, 106 ventricular septal defect occluders were correctly positioned. Transthoracic echocardiography revealed the insecure position or significant residual shunting in 10 patients. The original device was replaced with an asymmetric device or a more extensive occluder, and satisfactory results were finally obtained. No complications such as new-onset aortic regurgitation, residual shunt, complete heart block, or device dislodgement occurred during follow-up. CONCLUSION: Transthoracic closure of ventricular septal defects under the total guidance of transthoracic echocardiography is a safe and effective method.

Efficacy of transthoracic device closure versus traditional surgical repair on atrial septal defects: A systematic review and meta-analysis / 中国胸心血管外科临床杂志

@#Objective    To compare the effects of transthoracic device closure and traditional surgical repair on atrial septal defect systemically. Methods    A systematic literature search was conducted using the PubMed, EMbase, The Cochrane Library, VIP, CNKI, CBM, Wanfang Database up to July 31, 2018 to identify trials according to the inclusion and exclusion criteria. Quality was assessed and data of included articles were extracted. The meta-analysis was conducted by RevMan 5.3 and Stata 12.0 software. Results    Thirty studies were identified, including 3 randomized controlled trials (RCTs) and 27 cohort studies involving 3 321 patients. For success rate, the transthoracic closure group was lower than that in the surgical repair group (CCT, OR=0.34, 95%CI 0.16 to 0.69, P=0.003). There was no statistical difference in mortality between the two groups (CCT, OR=0.43, 95%CI 0.12 to 1.52, P=0.19). Postoperative complication occurred less frequently in the transthoracic closure group than that in the surgical repair group (RCT, OR=0.30, 95%CI 0.12 to 0.77,  P=0.01; CCT, OR=0.27, 95%CI 0.17 to 0.42, P<0.000 01). The risk of postoperative arrhythmia in the transthoracic closure group was lower than that in the surgical repair group (CCT, OR=0.56, 95%CI 0.34 to 0.90, P=0.02). There was no statistical difference in the incidence of postoperative residual shunt in postoperative one month (CCT, OR=4.52, 95%CI 0.45 to 45.82, P=0.20) and in postoperative one year (CCT, OR=1.03, 95%CI 0.29 to 3.68, P=0.97) between the two groups. Although the duration of operation (RCT MD=–55.90, 95%CI –58.69 to –53.11, P<0.000 01; CCT MD=–71.68, 95%CI -– 79.70 to –63.66, P<0.000 01), hospital stay (CCT, MD=–3.31, 95%CI –4.16, –2.46, P<0.000 01) and ICU stay(CCT, MD=–10.15, 95%CI –14.38 to –5.91, P<0.000 01), mechanical ventilation (CCT, MD=–228.68, 95%CI –247.60 to – 209.77, P<0.000 01) in the transthoracic closure group were lower than those in the traditional surgical repair group, the transthoracic closure costed more than traditional surgical repair during being in the hospital (CCT, MD=1 221.42, 95%CI 1 124.70 to 1 318.14, P<0.000 01). Conclusion    Compared with traditional surgical repair, the transthoracic closure reduces the hospital stay, shortens the length of ICU stay and the duration of ventilator assisted ventilation, while has less postoperative complications. It is safe and reliable for patients with ASD within the scope of indication.

Efficacy of transthoracic device closure versus surgical closure on ventricular septal defects: A systematic review and meta-analysis / 中国胸心血管外科临床杂志

@#Objective    To compare the effects of transthoracic device closure and surgical closure on ventricular septal defect systemically. Methods    A systematic literature search was conducted using the PubMed, EMbase, The Cochrane Library, VIP, CNKI, CBM, Chinese Clinical Trial Register, ClinicalTrials. gov and Wanfang Database up to July 31, 2016. Quality was assessed and data of included articles were extracted. The meta-analysis was conducted using RevMan 5.0 and Stata 14.0 software. Results    Eleven studies were identified, including 5 RCTs and 6 cohort studies involving 2 504 patients. For success rate, there was no statistical difference between the transthoracic closure group and the surgical closure group in RCT (RR=0.99, 95%CI 0.96 to 1.03, P=0.70); the success rate in the transthoracic closure group was lower than that in the surgical closure group in the cohort study (OR=0.21, 95%CI 0.08 to 0.55, P=0.002). Both  results of RCTs and cohort studies showed that compared with surgical closure, transthoracic device closure reduced duration of the operation (RCT MD=–79.38, 95%CI –95.00 to –63.76, P<0.000 01; cohort study MD=–66.26, 95%CI –71.20 to –61.31, P<0.000 01) and hospital stay (RCT MD=–2.10, 95%CI –2.65 to –1.55, P<0.000 01; cohort study MD=–3.99, 95%CI –6.03 to –1.94, P=0.000 1), and the patients with blood transfusion (RCT RR= 0.04, 95%CI 0.01 to 0.11, P<0.000 01; cohort study OR=0.01, 95%CI 0.00 to 0.13, P=0.001). In the transthoracic closure group the risk of postoperative arrhythmia reduced (RCT RR=0.20, 95%CI 0.13 to 0.32, P<0.000 01; cohort study OR=0.46, 95%CI 0.31 to 0.67, P<0.000 1). In the transthoracic closure group a higher postoperative valvular regurgitation risk in RCT induced (RR=1.45, 95%CI 1.07 to 1.96, P=0.02) and the rate of postoperative valvular regurgitation in cohort study reduced (OR=0.43, 95%CI 0.20 to 0.92, P=0.03). However, there was no statistical difference in postoperative residual shunt (RCT RR=0.96, 95%CI 0.57 to 1.62, P=0.89; cohort study OR=0.52, 95%CI 0.12 to 2.25, P=0.38). Conclusion    Transthoracic device closure can shorten duration of the operation, hospital stay and reduce the patients with blood transfusion and post- and intraoperative arrhythmia risk. Therefore, transthoracic device closure may be a better approach for some ventricular septal defect patients.

TEE guided minimally invasive transthoracic device closure of ventricular septal defect versus convention-al thoracotomy: a comparative study of propensity score matching / 实用医学杂志

Objective To compare the difference between transthoracic device closure of ventricular sep-tal defect and conventional thoracotomy and examine the effect and safety of transesophageal echocardiography (TEE) guided minimally invasive transthoracic device closure of ventricular septal defect. Methods Three hun-dred and sixty-eight patients underwent isolated ventricular septal defect surgery in our hospital from May 2014 to May 2016. There were 40 patients in group A underwent TEE guided minimally invasive transthoracic device clo-sure of ventricular septal defect and 328 patients in group B underwent conventional thoracotomy surgery.By using the method of propensity score matching,we selected 40 conventional thoracotomy patients as a control group in our study. Results All patients were survived after surgery without death and other serious complications. Compared with conventional thoracotomy surgery,patient with transthoracic device closure of ventricular septal defect had sta-tistical improvement in surgery time(1.97 ± 0.48 vs. 3.55 ± 1.95)h, ICU stayed time(21.15 ± 30.52 vs. 38.37 ± 10.91)h,volume of thoracic drainag(28.39 ± 32.67 vs.174.84 ± 85.36)mL,surgery incision length(2.98 ± 0.72 vs. 11.76 ± 2.89)cm.There were no significant differences in postoperative valvular regurgitation,arrhythmia and resid-ual shunt between the two groups.Conclusion TEE guided minimally invasive transthoracic device closure of ven-tricular septal defect is safe,effective,feasible,less trauma,less bleeding,faster recovery and etc.

Results of comparing transthoracic device closure and surgical repair with right infra-axillary thoracotomy for perimembranous ventricular septal defects.

OBJECTIVES: Transthoracic device closure (TTDC) and surgical repair with right infra-axillary thoracotomy (SRRIAT) are two main alternative minimally invasive approaches for restrictive perimembranous ventricular septal defect (VSD); however, few studies have compared them with each other in terms of effectiveness and cost. METHODS: Patients with perimembranous VSD undergoing TTDC or SRRIAT from January 2012 to July 2013 were reviewed in a comparative investigation between the two procedures. RESULTS: Success from the procedures was achieved in 30 TTDC (30/33, 91%) and 96 SRRIAT patients (100%). Operation duration in the TTDC group was significantly shorter than that of the SRRIAT group (115.8 ± 43.8 vs 175.6 ± 41.3 min, P < 0.01). The total perioperative drainage, use of red blood cells, mechanical ventilation time, stay in the intensive care unit and hospital stay for the TTDC group were significantly less than those in the SRRIAT group. No deaths or complete atrioventricular block occurred in either group. One SRRIAT patient accepted a second surgery for residual shunt. TTDC costs slightly more than SRRIAT (40270.6 ± 2741.3 renmingbi [RMB] vs 32964.5 ± 8221.6 RMB, P < 0.01). CONCLUSIONS: Both TTDC and SRRIAT showed excellent outcomes and cosmetic appearance for suitable VSD candidates. Although its costs were higher, TTDC had the advantages over SRRIAT of a short operation duration and intensive care unit stay and fewer days in the hospital.