Shouzheng Wang

Percutaneous Closure of Atrial Septal Defects Under Transthoracic Echocardiography Guidance Without Fluoroscopy or Intubation in Children

OBJECTIVE Demonstrate the benefits of percutaneous atrial septal defect (ASD) closure under guidance of transthoracic echocardiography (TTE) without fluoroscopy. METHODS From February 2013 to April 2014, 127 consecutive patients with an isolated type II ASD were recruited to undergo percutaneous closure under either TTE (n = 60, TTE group) or TEE (n = 67, TEE group) guidance. The TTE group received local anesthesia or sedation with propofol, and the TEE group received general anesthesia with endotracheal intubation. Follow-up examinations were performed for both groups at 1 month, 3 months, 6 months, and 1 year after discharge and annually thereafter. RESULTS The TTE group had a significantly shorter procedure time and respirator ventilation duration than the TEE group. The dose of propofol required, the cost, and the pharyngeal complication rate were significantly lower in the TTE group than in the TEE group. The median follow-up of 11.6 months was uneventful in all patients. CONCLUSIONS Percutaneous ASD closure with TTE guidance as the only imaging tool avoids fluoroscopy, endotracheal intubation, and probe insertion and is associated with a satisfactory procedural success rate and lower costs. This procedure is a safe and reliable treatment for ASD.

Echocardiographic Guided Closure of Perimembranous Ventricular Septal Defects

BACKGROUND Transesophageal echocardiogram-guided minimally invasive periventricular device closure of perimembranous ventricular septal defects (pmVSDs) without cardiopulmonary bypass is a treatment option for pmVSDs. We introduce our improvements to this technique and mid-term follow-up results. METHODS From May 2011 to May 2014, 187 patients with pmVSDs aged 6 months to 31 years (8.2 ± 10.2 years) were enrolled in this study. The procedure was performed through a new transthoracic approach of 1 to 2 cm without sternotomy. Device selection and the operative procedure were monitored by transesophageal echocardiogram. The patients underwent follow-up examinations of echocardiography and electrocardiogram at 1 month, 3 months, 6 months, and 1 year after the operation and annually thereafter. RESULTS The defects were closed successfully in 179 patients (95.7%), and in 8 patients the operation was converted to conventional surgical repair. Six patients (3.4%) had an incomplete right bundle branch block. One patient experienced an intermittent complete atrioventricular block on the fourth day after the operation, and sinus rhythm was restored by corticosteroid therapy after 5 days. A trivial residual shunt was observed in 8 patients (4.5%) during the procedure. The average hospital stay was 3.1 ± 0.9 days. Follow-up in all patients ranged from 1 month to 36 months (median, 12.6 months), and aortic regurgitation, malignant arrhythmia, and device dislocation were not observed in any patients. However, 3 patients (1.7%) still had a trivial residual shunt at their last follow-up. CONCLUSIONS Periventricular device closure through a modified transthoracic approach without sternotomy is a potentially safe and effective treatment option for pmVSDs. Controlled studies with long-term follow-up are necessary.

First-in-Human Percutaneous Balloon Pulmonary Valvuloplasty Under Echocardiographic Guidance Only.

OBJECTIVE The objective of this study was to assess the feasibility of percutaneous balloon pulmonary valvuloplasty (PBPV) under echocardiographic guidance only. SETTING PBPV has become the preferred choice for pulmonary valve stenosis (PS). We report the first-in-human successful PBPV under only echocardiography guidance for isolated PS. METHODS From March 2013 to December 2014, 34 patients with congenital PS underwent PBPV with echocardiography as the only imaging modality in the ordinary operation room or catheter lab. Outpatient follow-up including chest radiography, electrocardiography, and transthoracic echocardiography (TTE) was conducted at 1, 3, 6, and 12 months. RESULTS All 34 patients successfully underwent PBPV under echocardiography guidance without radiation and contrast agent. The pulmonic transvalvular pressure gradient dropped from 62.8 ± 10.1 mm Hg to 14.7 ± 4.2 mm Hg measured on catheterization (P < .05). The balloon diameter/pulmonary annulus diameter ratio was 1.34 ± 0.07. Slight regurgitation of the pulmonary valve occurred in five patients and mild pulmonary regurgitation occurred in one patients. The pulmonic transvalvular pressure gradient measured on TTE 12 months after the procedure was 14.1 ± 4.6 mm Hg. No pericardial effusion and peripheral vascular complications occurred. CONCLUSION This study demonstrated that PBPV can be successfully performed under only echocardiography guidance and appears safe and effective while avoiding radiation and contrast agent use.

Transcatheter perimembranous ventricular septal defect closure under transthoracic echocardiographic guidance without fluoroscopy

Background Transcatheter device closure has become an alternative therapy for ventricular septal defect (VSD). This study aimed to investigate the feasibility and safety of transcatheter perimembranous VSD (pm-VSD) closure under transthoracic echocardiography (TTE) guidance alone. Methods Between October 2012 and July 2016, 118 patients with pm-VSD underwent an attempt of transcatheter device closure for pm-VSD through the femoral artery under TTE guidance alone. Patients were followed-up at 1, 3, 6, and 12 months after the procedure and yearly after discharge. Results The mean age was 11.7±12.5 years (range, 1.0-53.0 years) and the mean body weight was 32.2±21.6 kg (range, 11.5-102.0 kg). The mean diameter of the VSD was 4.0±1.1 mm (range, 3.0-8.0 mm). Transcatheter device closure under TTE guidance alone was successful in 111 patients. The average procedural time was 44.9±7.3 minutes (range, 29.0-65.0 minutes). All 111 patients were followed-up for 3.4±2.3 years. At the last follow-up, two patients had a residual shunt smaller than 2 mm, seven patients had right bundle branch block (RBBB) including one patient with complete RBBB, six patients had mild or less tricuspid regurgitation, and two patients still had trivial aortic regurgitation including one patient that had it before the procedure. Occluder malposition, complete atrioventricular block, or other complications were not observed. Conclusions Transcatheter pm-VSD closure can be successfully performed under TTE guidance alone with outcomes similar to those achieved with fluoroscopic guidance in selected patients with weight more than 10 kg and VSD smaller than 8 mm. However, long-term follow-up in a large number of patients would be necessary.

A novel totally biodegradable device for effective atrial septal defect closure: A 2-year study in sheep

OBJECTIVE To evaluate the feasibility, efficacy, and safety of a fully biodegradable poly lactic acid (PLA)-based occluder for atrial septal defect (ASD) closure in an animal model. METHODS ASDs, approximately 12-mm in diameter, were generated in sheep (n = 18) by needle puncture and balloon dilatation. For ASD closure, occluders were implanted by percutaneous transcatheter approach under echocardiographic guidance. Outcomes were evaluated by transthoracic echocardiography, electrocardiography, blood testing, and histology within the follow-up period ranging from 1 month to 2 years. RESULTS All occluders were successfully implanted. During follow-up, no animal died; rectal temperatures, blood test results, and electrocardiograms were within normal ranges; and transthoracic echocardiograms, macroscopic studies, and histopathological and electron microscopic examination demonstrated that the occluders were well positioned, with no shifting, residual shunts, severe inflammation, thrombus formation, atrioventricular valve insufficiency, cardiac erosion or arrhythmias. The occluders gradually embedded into the endocardial tissue of the hosts with complete endothelialization and disk absorption at 12 months, and a distinct molecular weight decrease of the framework (to 9% of initial) at 24 months after implantation. CONCLUSIONS In a sheep model, the use of totally biodegradable occluders appears feasible, efficacious and safe for ASD closure. Studies in humans are ongoing.

A Novel Guide Wire Facilitates Percutaneous and Nofluoroscopic Procedure for Atrial Septal Defect Closure

Objective: The purpose of this pilot study was to assess the safety and efficacy of a novel ultrasound guided wire for the treatment of patients with atrial septal defect (ASD) who underwent percutaneous atrial septal defect closure using transthoracic echocardiographic (TTE) guidance only. Materials and methods: From November 2017 to December 2017, 10 patients with congenital ASD were recruited for echo-guiding occlusion with a new designed wire specialized for percutaneous and no-fluoroscopic procedure. The novelty of this wire lies in the elastic spindleshaped tip which helps with precise positioning under ultrasound while reducing difficulty and complications. Operations were performed by 3 doctors who had performed no more than 10 echo-guided cases. Operative successful rate was used as the main evaluation index, Secondary evaluation index included operative time, the number of times guide wire or delivery system dropped into right atrial, frequency of arrhythmia, the number of times guide wire went through tricuspid valve, cardiac perforation, cardiac tamponade and peripheral vascular complications. Result: All 10 patients successfully underwent percutaneous and no-fluoroscopic atrial septal defect closure with the novel wire. The mean operation time was 20.20±8.904 minutes. The followup time was 3 months and no severe complication occurred. Conclusion: This pilot study demonstrated that the new ultrasound guided wire can be precisely positioned under ultrasound and can facilitate percutaneous and no fluoroscopic procedure safely and effectively.

Feasibility and effectiveness of percutaneous balloon mitral valvuloplasty under echocardiographic guidance only

Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice in patients with isolated mitral stenosis. This study aimed to assess the feasibility of PBMV under echocardiography guidance only of isolated mitral stenosis (MS).

Perventricular device closure of perimembranous ventricular septal defect: effectiveness of symmetric and asymmetric occluders

Objectives To assess safety and effectiveness of symmetric and asymmetric occluders in perventricular device closure without cardiopulmonary bypass of perimembranous ventricular septal defects (pmVSDs). Methods The present retrospective study enrolled 581 patients who underwent perventricular device closure of pmVSDs under transoesophageal echocardiography guidance from May 2011 to April 2016, and outpatient electrocardiography and transthoracic echocardiography assessments at 1, 3, 6 and 12 months, and yearly thereafter. Results The overall success rate of device implantation was 92.6% (43 surgical conversions immediately). Between patients receiving symmetric ( n  = 353) and asymmetric ( n  = 185) occluders, there were no significant differences in age, weight and defect diameter distributions; however, both before discharge and at mean 28.6 ± 21.2 (range, 1-60)-month follow-up, the symmetric group had lower rates of trivial residual shunt (5.7% vs 11.4%, P  = 0.018; and 0.8% vs 5.9%, P  = 0.001) and bundle branch block (0.8% vs 5.4%, P  = 0.002; and 0.6% vs 3.8%, P  = 0.009); and at follow-up, the asymmetric group had lower residual shunt (47.6% vs 85.0%, P  = 0.020) and similar branch block (30.0% vs 33.3%, P  = 1.000) disappearance rates. There were no severe complications, i.e. aortic regurgitation, malignant arrhythmias, haemolysis or device dislocation. Conclusions Perventricular device closure of pmVSDs appears safe and effective with symmetric and asymmetric occluders. However, the lower residual shunt disappearance and higher branch block incidence rates for asymmetric occluders would favour more proactive conversion to surgical repair immediately when residual shunt is present intraoperatively.