| Background:Complete closure of apical muscular ventricular septal defect(AmVSD)may be difficult,either performed via open heart surgery or percutaneous approach.This is true in children,especially in infants with large or multiple-holed AmVSDs.Open heart surgery although once gold standard,the technique is associated with defect identification and access challenges,and use of cardiopulmonary bypass machines in infants and underweight children is associated with morbidity and mortality.The percutaneous approach although favoured in adults and older children,its application in infants is hampered by limitation in vessel calibre and associated complications.Objective:The aim of this clinical research study was to report on the percadiac device occlusion of AmVSD using a probe-assisted delivery system,under exclusively transoesophageal echocardiography guidance as an alternative technique to both open heart surgery and percutaneous approaches in infants,and evaluate its efficacy,safety and mid-term results.Methods.For a period of seven years up to 2019/11,38 infants underwent percardiac device closure of AmVSD in our Cardiovascular Surgery Department.The cohort composed of 23 females,with overall mean age 7.2±3.5(1.5-12)months old.Of the total AmVSDs,24(63%)and 14 were single and multiple-holed defects.The average AmVSD size measured 6.9±2.9mm.The AmVSD color Doppler interrogation isolated three distinctive defect configurations,thus:the Cylindrical-shaped,the Tunnel-shaped and the Cave-like shaped.Based on cardiac access window,device deployment technique and coexisting congenital heart defects,the subjects were divided into three groups as follow:group A;the heart was accessed through partial inferior mini-sternotomy and device deployed using perventricular technique,group B;the heart was accessed through mini-thoracotomy and device deployed using peratrial technique,and group C;due to coexisting congenital heart defects required repair on cardiopulmonary bypass machine after AmVSD occlusion,the heart was accessed through complete midline-sternotomy and device deployed using perventricular technique.After general anesthesia and administration of anticoagulant as per local protocol,the heart was accessed via either of the above described cardiac access window.Two opposite pursue strings sutures were place on a preferred chamber.Under exclusive transoesophageal echocardiography guidance,either the J-or Z-probe was introduced via the purse strings circle puncture and advanced to access the AmVSD.Upon satisfactory alignment of the probe with the defect,or defect cross over,auxiliary deployment instruments of the probe-assisted delivery system were sequentially utilized to access the AmVSD and an appropriately sized device(s)was implanted.Results.A total of 48 devices measuring 8.2±2.6mm were successfully implanted in 38 patients(100%).Twenty-six(68%)and 12 patients had AmVSDs accessed using the J-and Z-probe respectively.Six patients from group A with extra lesions received one extra device each,while 4 patients with Swiss-cheese AmVSD received one extra device too.Of the cohort,2 patients were redo cases.Comparative intracardiac manipulation,procedure and intubation times were shorter in group B than group A(p<0.01).The left ventricular end diastolic dimensions decreased at 1-month follow-up(p=0.002).The complete closure rate at 36-month follow-up was 68%.The insignificant residual shunts persisted predominantly amongst multiple-holed AmVSDs,and closure rate was maintained at about 70%during the remaining follow-up period.The 9 patients(24%)from Group C underwent repair of congenital heart defects on cardiopulmonary bypass machine after AmVSD occlusion.There was no early(late)death or major device-related complications recorded,except a single case of post occlusion hematuria due to hemolysis which disappeared 7days later.All patients exhibited improvement in symptoms and heart function.Conclusions.The Percardiac device occlusion of AmVSDs as an alternative approach is feasible,efficacious,simple and safe in pediatric patients,regardless of age,weight and clinical status.While the perventricular deployment route befitted large and‘complex' AmVSD,the peratrial exhibited shorter procedure and intracardiac manipulation times,less invasiveness and better cosmetic outcome.Insignificant residual shunt rate remained relatively high amongst cave-like and multi-holed AmVSDs during the late follow-up period.Overall,in relation to available treatment options,the results have been encouraging. |
PDF Full Text Request