| ObjectiveTo evaluate the safety and efficacy of transcatheter closure of VSD as well as the long-term prognosis of the children who underwent the procedure.MethodFrom June 2002 to December 2018,a total of 988 children with VSD in the Department of Pediatric Cardiology,Shandong Provincial Hospital were enrolled,All children underwent transthoracic echocardiography(TTE),electrocardiogram(ECG)and chest roentgenogram before and after the treatment.Follow-up evaluation was done at 1,3,6,12 months and every year thereafter with TTE,ECG as well as chest X-ray.The collected data were analyzed by the IBM Statistical Package for Social Sciences version 23.0.Results1.40 children gave up occluding in 1028,and 988 children were occluded,938 cases were successful,and the rate of success was 94.9%(938/988).Basic information on successful children:male 473,female 465,the mean age was 4.69±2.75 years(1.7～18 years),the mean weight was 19.10±8.85kg(9.00～77kg),the mean defect’s size measured by TTE was 6.98±2.99mm(1.90～18.10mm),the mean size of the defect measured by angiography was 6.45 ± 3.48mm(1～18.00mm),,A total of 943 VSD occlusion devices were implanted,of which 5 patients were implanted in 2 occluder,the average diameter of occluder was 6.39±2.13mm(3～18.00mm),Within 24 hours after operation,the left atrial diameter of the echocardiogram decreased from(2.35±0.39)cm to(2.20±0.32)cm,and the left ventricular end-diastolic diameter decreased from(3.71±0.51)cm to(3.50±0.42)cm.they have a significant difference(t1=12.266 P1=0.000,t2=15.502 p2=0.000).2.The early postoperative complications were as follows:1 patient(0.11%)died of diffuse subarachnoid hemorrhage after surgery.Complete atrioventricular block occurred in 1 patient(0.11%),and he recovered after the use of dexamethasone and implantation of temporary pacemaker for 18 days.High atrioventricular block occurred in 2 patients,and one became complete right bundle branch block after the use of dexamethasone and implantation of temporary pacemaker for 11 days,the other one became normal after the use of dexamethasone for 18 days.Mechanical hemolysis occurred in 16 cases(1.71%),and they recovered before discharge after conservative treatment such as fluid liberalization,and urine alkalinization.15 patients(1.60%)developed CLBBB,13 of whom were treated with dexamethasone restored normal conduction when they were discharged.One patient underwent surgery to remove the occluder and repaired the defect,discharged with the normal electrocardiogram,one patient still had CLBBB.The other new onset of arrhythmias were:47(5.01%)complete right bundle branch block(CRBBB),26(2.77%)left anterior branch block(LABB),5(0.53%)Ⅰ° AVB,2(0.21%)Ⅱ° IAVB,2(0.21%)Ⅱ°Ⅱ AVB.Residual shunt occurred in 191 cases(20.36%),including 61 cases(6.50%)with residual shunt>1 mm and 130 cases(13.86%)with residual shunt≤1mm.New-onset tricuspid regurgitation(TR)occurred in 265 patients(28.25%),of which 192 patients(20.47%)with a small amount of TR,60 cases(6.40%)with mild TR,8(0.85%)with mild to moderate TR,and 5 patiernts(0.53%)with moderate.Aortic regurgitation(AR)occurred in 85 patients(8.89%),including 31 patients(3.30%)with the trivial of AR,45 patients(4.80%)with a small amount of AR,8 patients(0.85%)with mild AR,and 2(0.21%)with mild to moderate AR.3.Total follow-up data were available in 802 patients(85.5%),The postoperative follow-up period ranged from 1 to 192 months,with a median of 24 months.The follow-up rates were 85.5%,83.4%,80.20%,69.05%,48%in the follow-up periods of 1months,6months,lyear,5years,10years.At the end of follow-up,the cardiothoracic ratio decreased to 0.48±0.07 from 0.53±0.04 before surgery,and the difference was statistically significant(t=-9.225,P--0.OOO).The left ventricular size(4.57=0.35)cm in the patients followed up for more than 10 years after operation has no significant difference in normal outpatients’ left ventricular size(4.50±0.30)cm at the same time(t=1.171,P=0.251).4.The follow-up complications were as follows:the child who occurrd CAVB during early postoperative period became II°I AVB in the end,Among the 2 children with high atrioventricular block,one patient died in 3 months after the operation,and the other one re-occurred in the first year after the procedure and implanted with permanent pacemaker.15 patients with CLBBB,1 patient died,2 cases were lost to follow-up,3 patients with CLBBB(among them,two cases developed CLBBB again who recovered to normal ECG after treatment during early postoperative period),and 9 patients had an normal ECG 1 patient occurred Ⅲ°AVB after the procedure for 4 years and implanted permanent pacemaker;CLBBB occurred to two patient in 6 months after the operation.5.Different types of VSD:the difference between the successful rate of intracristal and perimembranous VSD was statistically significant(84.8%to 95.4%,;X2=7.649,Pt=0.006),Before and after propensity score matching their short-term and mid-and-long-term complications had no difference in incidence.No difference in the successful rate ofperimembranous VSD with aneurysm or not,so as the in incidence of complications after propensity score matching.The difference in the success rate of the diameter of the defect]10mm and diameter<10mm was statistically significant(92.8%vs 96.1%,2=3.961,P=0.047),and there was difference only in the incidence of residual shunt was stat:istically significant for them before and after PSM.There was a statistically significant difference in the success rate of distance from lesion to aortic valve<2mm and the distance)2mm(91.3%vs 98.4%,x2=12.154,P=0.000)and no statistically significant difference in the incidence of complications before and after PSM.6.Different types of occluder:In the short-term follow-up,the incidence of residual shunt of thin-waist-big-side occluder was statistically significant(P<0.007),and there was a statistically significant difference in the incidence of arrhythmia between eccentric and symmetrical occluder(P<0.007).In the mid-and-long-term follow-up,the difference in the incidence of AR between symmetrical and eccentric occluder was a statistically significant(P<0.007),so as the difference in the incidence of residual shunts and arrhythmia between thin-waist-big-side,eccentric and symmetrical occluder(P<0.007).There was no difference in the incidence of complications between the symmetrical occluder and the ADO II.There was a statistically significant difference in the incidence of residual shunt between the lengths of occluder waist is 4mm or 3mm,so as the incidence between the diameter of occluder>6mm and diameter≤6mm.7.Different age groups:2～3,3～4,4～6,6～18 years old,No difference in successful rate for different age groups(x2=11.360,P=0.715),There was a statistically significant difference in the incidence of residual shunt in short-term follow-up and no difference in the mid-and-long-term.Conclusions1.With selecting the patient strictly,transcatheter closure of ventricular septal defects can be safe and successful with low morbidity and mortality.Mid-and-long-term prognostic results are favourable,and it can become the first choice in selected patients.2.Different age groups:,children with 2-3 years old had the same successful rate as children in other age groups,and there was no increasing trend of complications during the mid-and-long-term follow-up.For patients with VSD of 2 to 3 years old who met the indications for closure,transcatheter closure is preferred.3.In different types of VSD,the intracristal VSD has a lower successful rate,their short-term and mid-and-long-term follow-up is effective.The successful rate of perimembranous VSD with sub-aortic rim<2mm is lower,but there is no difference in the incidence of complications.pmVSD with aneurysm or not has no difference in successful rate and the incidence of complications.The incidence of residual shunt was relatively high in VSD≥10 mm in diameter.4.In different types of occluder,eccentric occluder is closely related to arrhythmia and aortic regurgitation.The thin-waist-big-side occluder is closely related to residual shunts as well as arrhythmias.ADOII type occluder is safe and reliable for blocking of VSD.The occluder with 4mm-waist is more prone to residual shunting,so as the occluder≥6 mm in diameter.5.CAVB and CLBBB appearing early after transcatheter closure can be recovered to normal ECG after hormone,and some of them can reoccur during the long-term follow-up,and even died.Removing the occluder early and repairing VSD has the potential to restore normal ECG. |
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