Perventricular VSD closure

Perventricular VSD closure 

Perventricular VSD closure is a hybrid procedure in which the cardiac surgeon opens the chest and the cardiologist passes a sheath through the right ventricle to achieve a device closure of the ventricular septal defect (VSD). Hybrid procedures are done in hybrid suites with facility for both open heart surgery and radiographic equipment for cardiac catheterization and angiography (hybrid of open heart surgery theatre and cardiac catheterization laboratory or cathlab). Heart is exposed through a lower partial sternotomy. The advantage is that cardiopulmonary bypass is not needed. Intra operative trans esophageal echocardiography is used to confirm the size of the defect, its rim from the aortic valve and the function of the aortic valve. The location of the ventricular septal defect is determined intraoperatively by palpating the region over the right ventricle with maximum intensity of the thrill due to left to right shunt. The site for puncture is further confirmed by trans esophageal echocardiography (TEE). The perventricular VSD closure system has a trocar for introduction through the right ventricle, a dilator, sheath for delivery of device and the VSD closure device. The trocar is introduced through a purse string suture for control of bleeding. Guide wire and sheath introduction is under continuous TEE guidance. Sheath is de-aired by allowing a back bleed. The device occluder’s right ventricular disc is secured by a suture to facilitate retrieval if needed. After accurate device positioning, the suture can be cut and removed. TEE confirms the device position as well the good functioning of aortic and tricuspid valves. Cardiac rhythm is also checked to exclude conduction disturbances before the device delivery is established. As with other device closures, aspirin is given for a period three months during which the device is expected to get endothelialized.

Large VSDs in the apicomuscular region is difficult for the surgeon to access in small children. These defects require large sheaths for device closure and the local complications are higher in small children because of the relative larger sheaths for the size of the child. Molaei A et al report perventricular closure of such a defect with guidance of epicardial echocardiography [1]. The three year old child had multiple adjacent apicomuscular defects, the largest of which was 19 mm. It was closed with a 22 mm device. Only small residual shunt from adjacent small VSDs remained. Child was stable at 2 year follow up.

A larger multicentric report of perventricular closure of 47 muscular VSDs has also been published [2]. At mid term follow up of mean 19.2 months, none had delayed development of AV block, increase in AV valve insufficiency or ventricular dysfunction. 90% had complete closure of the muscular VSDs.

Another study reported perventricular VSD closure with left infra-axillary mini-incision [3]. They used this approach for perventricular closure of 45 doubly committed sub-arterial ventricular septal defects which were less than 8 mm in diameter. 

A multicenter randomized controlled trial comparing minimally invasive perventricular VSD closure vs surgical closure for treatment of perimembranous ventricular septal defect has been published [4]. 100 patients were enrolled and randomized in the study. The perventricular closure group had superiority in procedural duration, ventilation time, chest tube output volume, post operative hospitalization time and hospitalization cost compared to the surgical group.

 References

1. Molaei A, Afrasiabi A, Bilejani E, Samadi M. Perventricular Muscular Ventricular Septal Defect (VSD) Closure under Epicardial Echocardiography Guidance: A Case Report. J Tehran Heart Cent. 2017 Jul;12(3):138-141.
2. Gray RG, Menon SC, Johnson JT, Armstrong AK, Bingler MA, Breinholt JP, Kenny D, Lozier J, Murphy JJ, Sathanandam SK, Taggart NW, Trucco SM, Goldstein BH, Gordon BM. Acute and midterm results following perventricular device closure of muscular ventricular septal defects: A multicenter PICES investigation. Catheter Cardiovasc Interv. 2017 Aug 1;90(2):281-289.
3. Zhou S, Zhao L, Fan T, Li B, Liang W, Dong H, Song S, Liu L.Perventricular device closure of doubly committed sub-arterial ventricular septal defects via a left infra-axillary approach. J Card Surg. 2017 Jun;32(6):382-386.
4. Lu W, Zhang F, Fan T, Zhao T, Han Y, Hu X, Li Q, Shi H, Pan X. Minimally-invasive-perventricular-device-occlusion versus surgical-closure for treating perimembranous-ventricular-septal-defect: 3-year outcomes of a multicenter randomized clinical trial. J Thorac Dis. 2021 Apr;13(4):2106-2115.