Diana Negura

Transcatheter closure of perimembranous ventricular septal defects. Early and long-term Results

OBJECTIVES We sought to analyze safety, efficacy, and follow-up results of percutaneous closure of perimembranous ventricular septal defects (pmVSD). BACKGROUND Results of pmVSD transcatheter closure have been reported in the literature; however, follow-up data are still limited. METHODS Between January 1999 and June 2006, 104 patients underwent percutaneous closure of a pmVSD at our institution. An Amplatzer VSD device (muscular or eccentric) (AGA Medical Corp., Golden Valley, Minnesota) was used in all subjects. RESULTS The mean age at closure was 14 years (range 0.6 to 63 years). The attempt to place a device was successful in 100 patients (96.2%). The median device size used was 8 mm (range 4 to 16 mm). No deaths occurred. Total occlusion rate was 47% at completion of the procedure, rising to 84% at discharge and 99% during the follow-up. A total of 13 early complications occurred (11.5%), but in all but 2 subjects (1.9%) these were transient. The median follow-up was 38.5 months. The most significant complication was complete atrioventricular block (cAVB), which required pacemaker implantation in 6 subjects (5.7%; 2 in the early phase and 4 during the follow-up). Cox proportional hazards regression analysis showed that the only variable significantly associated with the occurrence of this complication was age at the time of the procedure (p = 0.028; relative risk 0.25). All subjects experiencing this problem were <6 years old. CONCLUSIONS In the current era and in experienced hands, pmVSD closure can be performed safely and successfully. The major concern is the occurrence of cAVB; therefore, very careful monitoring of rhythm is mandatory during follow-up.

Clinical ResearchCongenital Heart DiseaseTranscatheter Closure of Perimembranous Ventricular Septal Defects: Early and Long-Term Results

OBJECTIVES We sought to analyze safety, efficacy, and follow-up results of percutaneous closure of perimembranous ventricular septal defects (pmVSD). BACKGROUND Results of pmVSD transcatheter closure have been reported in the literature; however, follow-up data are still limited. METHODS Between January 1999 and June 2006, 104 patients underwent percutaneous closure of a pmVSD at our institution. An Amplatzer VSD device (muscular or eccentric) (AGA Medical Corp., Golden Valley, Minnesota) was used in all subjects. RESULTS The mean age at closure was 14 years (range 0.6 to 63 years). The attempt to place a device was successful in 100 patients (96.2%). The median device size used was 8 mm (range 4 to 16 mm). No deaths occurred. Total occlusion rate was 47% at completion of the procedure, rising to 84% at discharge and 99% during the follow-up. A total of 13 early complications occurred (11.5%), but in all but 2 subjects (1.9%) these were transient. The median follow-up was 38.5 months. The most significant complication was complete atrioventricular block (cAVB), which required pacemaker implantation in 6 subjects (5.7%; 2 in the early phase and 4 during the follow-up). Cox proportional hazards regression analysis showed that the only variable significantly associated with the occurrence of this complication was age at the time of the procedure (p = 0.028; relative risk 0.25). All subjects experiencing this problem were <6 years old. CONCLUSIONS In the current era and in experienced hands, pmVSD closure can be performed safely and successfully. The major concern is the occurrence of cAVB; therefore, very careful monitoring of rhythm is mandatory during follow-up.

Transcatheter closure of atrial septal defect in young children: Results and follow-up

OBJECTIVES This study sought to analyze the safety, efficacy, and follow-up results of percutaneous closure of secundum atrial septal defect (ASD) in young children. BACKGROUND Results of ASD transcatheter closure in adults are widely reported but there are no large published series concerning young children. METHODS Between December 1996 and February 2002, 48 of 553 patients percutaneously treated at our institution were children age <or=5 years. Indications for closure were: elective closure in 32 patients; frequent respiratory infections in 8; failure to thrive in 2; liver transplantation in 5; and a fenestrated Fontan in 1. The procedure was carried out under general anesthesia with fluoroscopy and transesophageal control. Two different devices were used: 1) the CardioSEAL/StarFLEX (CS/SF) and 2) the Amplatzer septal occluder (ASO). Basal physical examinations and echocardiograms were performed prior to the procedure and at follow-ups (1, 6, and 12 months, and yearly thereafter). RESULTS The mean age at closure was 3.6 +/- 1.3 years. A CS/SF was used in 10 subjects; an ASO was used in 38 patients. No deaths or immediate major complications occurred. The total occlusion rate was 87% at procedure, rising to 94% at discharge. The mean follow-up was 18 +/- 14 months. No midterm major or minor complications occurred. The occlusion rate rose to 100% at 12 months of follow-up. Symptomatic patients improved significantly. CONCLUSIONS In the current era and in experienced hands, ASD closure can be performed safely and successfully, even in very young children.

Treatment of isolated secundum atrial septal defects: Impact of age and defect morphology in 1,013 consecutive patients

BACKGROUND Percutaneous closure of atrial septal defect (ASD) is a valid alternative to surgical approach. Current device has significantly improved the success rate also in complex cases. The aim of this study is to assess the impact of age, defect size, and morphologic features on successfully percutaneous ASD closure. METHODS Between January 2000 and September 2004, 1,013 consecutive patients underwent closure of an isolated type II ASD at our institution. The following outcomes have been evaluated: (1) role of percutaneous ASD closure as alternative to surgical repair, in current daily practice; (2) impact of age on the selected closure approach; (3) analysis of morphologic variety of ASD and its effect on the closure technique; (4) possible role of specific device selection according to ASD morphology to improve procedural success. RESULTS During the study period, up to 80% of secundum ASDs were suitable for percutaneous closure with the currently available devices. Need for surgical ASD closure was more common in pediatric patients, likely reflecting the more frequent diagnosis of larger and complex defects at a young age. Accurate ADS morphology assessment and appropriate device selection are key elements to obtain procedural success. In particular, among all the ASD characteristics, the rim absence is the main limiting factor to a successful percutaneous ASD closure. A trend of reduction in peri-procedural adverse events was observed during the study period, with complications needing immediate cardiac surgery occurred only in 1% of cases. CONCLUSIONS Percutaneous ASD closure is feasible and associated with low complication rate. A thorough analysis of morphologic aspects is mandatory in order to select the appropriate device and the optimal approach. Surgical closure remains the treatment of choice in selected patients.

A new 2D-based method for myocardial velocity strain and strain rate quantification in a normal adult and paediatric population: assessment of reference values

BackgroundRecent advances in technology have provided the opportunity for off-line analysis of digital video-clips of two-dimensional (2-D) echocardiographic images.Commercially available software that follows the motion of cardiac structures during cardiac cycle computes both regional and global velocity, strain, and strain rate (SR).The present study aims to evaluate the clinical applicability of the software based on the tracking algorithm feature (studied for cardiology purposes) and to derive the reference values for longitudinal and circumferential strain and SR of the left ventricle in a normal population of children and young adults.Methods45 healthy volunteers (30 adults: 19 male, 11 female, mean age 37 ± 6 years; 15 children: 8 male, 7 female, mean age 8 ± 2 years) underwent transthoracic echocardiographic examination; 2D cine-loops recordings of apical 4-four 4-chamber (4C) and 2-chamber (2C) views and short axis views were stored for off-line analysis.Computer analyses were performed using specific software relying on the algorithm of optical flow analysis, specifically designed to track the endocardial border, installed on a Windows™ based computer workstation. Inter and intra-observer variability was assessed.ResultsThe feasibility of measurements obtained with tissue tracking system was higher in apical view (100% for systolic events; 64% for diastolic events) than in short axis view (70% for systolic events; 52% for diastolic events). Longitudinal systolic velocity decreased from base to apex in all subjects (5.22 ± 1.01 vs. 1.20 ± 0.88; p < 0.0001). Longitudinal strain and SR significantly increased from base to apex in all subjects (-12.95 ± 6.79 vs. -14.87 ± 6.78; p = 0.002; -0.72 ± 0.39 vs. -0.94 ± 0.48, p = 0.0001, respectively). Similarly, circumferential strain and SR increased from base to apex (-21.32 ± 5.15 vs. -27.02 ± 5.88, p = 0.002; -1.51 ± 0.37 vs. -1.95 ± 0.57, p = 0.003, respectively).Values of global systolic SR, both longitudinal and circumferential, were significantly higher in children than in adults (-1.3 ± 0.2, vs. -1.11 ± 0.2, p = 0.006; -1.9 ± 0.6 vs. -1.6 ± 0.5, p = 0.0265, respectively). No significant differences in longitudinal and circumferential systolic velocities were identified for any segment when comparing adults with children.ConclusionThis 2D based tissue tracking system used for computation is reliable and applicable in adults and children particularly for systolic events. Measured with this technology, we have established reference values for myocardial velocity, Strain and SR for both young adults and children.

Transcatheter closure of congenital ventricular septal defects in adult : Mid-term results and complications

INTRODUCTION Transcatheter treatment of congenital heart defects in adult patients is dramatically changing the way in which this population is being treated. This report outlines mid-term follow-up results and complications in adult patients that underwent transcatheter VSD closure. METHODS The data of 40 adult patients who underwent transcatheter closure of a VSD at our institution were collected prospectively between January 2000 and June 2006. The inclusion criteria for this study were clinical and/or echocardiographic evidence of a significant left-to-right shunt through a muscular VSD (mVSD) or a perimembranous VSD (pVSD). A shunt was considered significant when the following were found: (i) left atrial enlargement, defined as a left atrial-to-aortic ratio >1.5; (ii) left ventricular enlargement (left ventricular overload), defined as a left ventricular end-diastolic diameter >+2 standard deviation (SD) above the mean for the patients age. Another inclusion criterion was a previous episode of endocarditis. RESULTS 41 procedures were carried out in 40 patients; a mVSD-O was used in 22 patients and a pVSD-O in 18 patients (1 patient had two devices inserted). No deaths occurred; no procedure was aborted. A total of 6 (14.6%) complications occurred. The most frequent complication was a rhythm abnormality (n=4). No device embolization occurred. The median follow-up duration was 36 months (range: 6-81 months). No deaths or cases of endocarditis occurred. One patient who had two devices implanted because of a residual defect after a tetralogy of Fallot repair, had to be operated again 3 months after the second device implantation because of a persistent significant residual leak. CONCLUSIONS Greater experience, possibly of multicentre trials and long-term follow-up are required to better assess the safety and effectiveness of this procedure as an alternative to surgical approaches in adult patients.

Covered stents in patients with congenital heart defects

Objectives: To evaluate the role of covered Cheatham‐Platinum stents in patients with congenital heart disease. Background: There are limited data in the literature about the use of covered stent in patients with congenital heart disease. Methods: Between January 2004 and September 2005, covered Cheatham‐Platinum stents were implanted into 18 patients with congenital heart defects (9 males, median age 19 years, range 8–45 years). Sixteen had aortic coarctation or recoarctation (8 with associated aneurysm, 1 with patent ductus arteriosus, 3 with an irregular wall, 4 with subatretic native aortic coarctation) (group 1). Two subjects with univentricular heart circulation were treated because of complex right‐to‐left shunting (Group 2). Results: Group 1: The stents used ranged from 34 to 45 mm in length. The mean fluoroscopy and procedure times were 12 ± 8 and 70 ± 15 minutes, respectively. After implantation, the gradient across the stenosis decreased significantly (prestent median value 37 mmHg) (range 20–50 mmHg) versus poststent: median value 0 mmHg (range 0–10 mmHg) (P < 0.0001). Vessel diameter increased from a median value of 6 mm (range 0–11) to a median value of 14 mm (range 10–23) (P < 0.0001). Stents were placed in the correct position in all subjects. No complications occurred and on angiographic control the stenoses had been relieved and the aneurysms completely excluded. Group 2: Implantation of the covered stents successfully abolished right‐to‐left shunting in both patients. Both had significant increases in oxygen saturation and no complications occurred. Follow‐up: During a median follow‐up of 7 months (1–19 months), the results were stable without any complications. Conclusion: Covered Cheatham‐Platinum stents are very useful tools for treating various congenital cardiovascular malformations.

Right and Left Ventricular Strain and Strain Rate in Young Adults before and after Percutaneous Atrial Septal Defect Closure

To evaluate acute change of right and left ventricle after percutaneous closure of isolated atrial septal defect (ASD) 21 adult patients (13 F; 8 M) aged 28 ± 9.5 range 18–49 years have been examined by echocardiography before and 24 hours after percutaneous closure of ASD. Twenty‐one normal adult subjects, as control group were included. A MyLab25 echo machine equipped with a multifrequency 2.5–3.5 MHz transducer was used. Offline computer‐based analysis for strain and SR were performed using XStrain software based on a feature tracking algorithm. All patients had ASD OS2 with right ventricular dilatation and diastolic areas were larger than in controls: P = 0.0158. Global right ventricular longitudinal strain was higher P = 0.0438. Twenty‐four hours after ASD closure, right ventricular diastolic and systolic areas were significantly reduced. Right ventricular global longitudinal systolic strain decreased: P = 0.00016, as well as global right ventricular longitudinal SR –1.56/sec ± 0.57 vs. –1.28/sec ± 0.31, P = 0.02646. At the mean time left ventricular end diastolic volume and left ventricular cardiac output measured by two‐dimensional echocardiography both increased significantly P = 0.002145 and 0.013409. Global circumferential strain at mitral level augmented significantly –20.3%± 4.64 vs. –25.39%± 5.22, P = 0.00003. Longitudinal strain of the right ventricle works as indicator of right ventricular function dependent on loading conditions while SR seems to be less dependent on it. Circumferential strain could be used as an indicator of left ventricular response to normalized loading conditions. (Echocardiography 2011;28:730‐737)

Transcatheter closure of postsurgical residual ventricular septal defects: early and mid-term results.

Background: The incidence of residual ventricular septal defects (VSDs) after surgery is 5–25%. Redo surgery is associated with higher risks. Methods: Between January 2000 to December 2008, 170 patients underwent percutaneous VSD closure in our centre: 22(16M) of these had 23 closures for residual VSDs. Median age was 32.5 yrs (1.4–79). All patients had echocardiographic signs of left ventricle volume overload (Qp/Qs ≥ 1.5). Nine patients had previous VSD closure, 6 tetralogy of Fallot repair, and 7, other procedures. There were 15 muscular, 6 perimembranous and 2 apical VSDs. Results: Amplatzer VSD devices were used in all. Median VSD size was 8 mm (4.3–16). Median fluoroscopy time was 33 minutes (15–130). There were three adverse events: 1 ventricular fibrillation requiring DC cardioversion; 1 transient complete atrio‐ventricular block reverting to sinus rhythm at 24‐hours; one patient had transient atrial flutter during the procedure. All procedures were successful; no additional procedures were required. Trivial residual shunts were seen in 3 patients at follow‐up. There were no late events. One patient experienced arrhythmic death 5‐yrs after procedure. One patient was reoperated due to dehiscence of VSD patch 2‐yrs after the second successful percutaneous closure. Conclusions: Transcatheter closure of postsurgical residual VSD is safe and efficacious management option and obviates the need for further surgery and by‐pass.

The impact of interventional cardiology for the management of adults with congenital heart defects

The objective of this study is to assess the impact of interventional cardiology procedures for the management of ACHD. The interventional approach to the management of CHD in the adult population is becoming increasingly recognized as the preferred treatment option for a wide number of congenital cardiac conditions. The files of all consecutive patients over 18 years of age who were hospitalized in our department from January 2000 to December 2004 were reviewed. Over the study period, 1,115 ACHD (583 women; mean age 41 ± 13.8, years, range 18–72 years) were hospitalized in our department; 752 patients underwent cardiac catheterization and 82.4% of them had an interventional procedure carried out. ASD (329/620) and PFO (159/620) closure account for 78% of all the procedures carried out, with a 2.7% of major complications incidence (all of them closing ASDs). Other procedures such as stenting aortic coarctation (40/620), ventricular septal defect closure (33/620), patent ductus arteriosus embolization (30/620), pulmonary valvuloplasty (12/620), stenting pulmonary artery branches (8/620), etc (5/620) were carried out. The most important complication was one death, which occurred in the case of a 22‐year‐old woman after stent implantation for a recurrent aortic coarctation. A trivial residual shunt was detected in only 5% of the patients who had a 6‐month follow‐up after VSD closure; no residual shunt was found after PDA embolization during the 12‐month follow‐up. In conclusion, we believe that the interventional approach is a safe and successful treatment option for a wide number of congenital cardiac conditions. The increasing use of catheter interventions for these patients will be responsible for an increase of complex cases in surgery.