Perimembranous VSD

Incidence of isolatedventricular septal defects• Most common congenital heartdisease (CHD) (20% of all CHD)• 80% → perimembranous VSD(pm VSD)

Indications for surgicalVSD Closure• Relevant shunt:- Qp/Qs > 2 : 1 and LV volume overload- Qp/Qs > 1.5 : 1* and• PA pressure < 2/3 of systemic pressure andPVR < 2/3 of systemic Vascular resistance- Qp/Qs > 1.5 : 1 and• LV systolic or diastolic failure• History of endocarditis*CCS Guidelines 2006, AHA Guidelines 2008

Exclusion criteria forpercutanous VSD closure• Overriding aorta• Supracristal VSD• Associated significant aortic regurgitation• Prolapse of aortic cusp• Sub-aortic stenosis• Sub-pulmonary stenosis• Eisenmenger syndrome

Signs for small VSDMany VSD are small and do not require closure• Echo:- Asymptomatic- High velocity jet through VSD- No LV volume overload- No pulmonary hypertension• Catheterization:- Qp:Qs < 1.5- Mean pulmonary artery pressure < 25 mmHg- Low PVR < 200 dyn.s.cm -5

Exclusion criteria forpercutaneous VSD closureoverriding aortaprolapse of aortic cusp

Exclusion criteria forpercutaneous VSD closureEisenmenger syndromeRV RVCourtesy: Neil Wilson,TEE 0˚

VSD-Closure Devices• Clamshell, Cardioseal-/Cardioseal-Starflex– ~ 300 patientsJ Lock, Boston

Amplatzer Closure Devices• ASD (4-36 mm)• VSD (4-18 mm)• Post-MI VSD (16-24 mm)• Perimembraneous VSD

Perimembranous VSDClose proximity to tricuspid and aortic valveas well as to conduction system

Perimembranous VSDEcho evaluation• Size (Measurements in different planes)• Number (single/multiple)• Anatomy of funnel (aneurysmal orserpiginous defects?)• Rim to aortic valve?• Associated defects (ASD/ pulmonarystenosis/aortic coarctation/…)• Contra-indications to percutaneous closure

Perimembranous VSDEcho evaluation• TTE views- Parasternal LAX and SAX views- Apical 4 and 5 chamber views- Subcostal views

Perimembranous VSDEcho evaluation• TEE views- Mid- esophageal 4 and 5 chamber views (0˚)- Mid-esophageal LAX view (130 ˚)- Mid- low esophageal SAX view (30-35 ˚)

Perimembranous VSDTTE LAX view

Perimembranous VSDTTE LAX view (zoom)Measurement: 8mm

Perimembranous VSDTTE SAX view

Perimembranous VSDTTE 4/5 chamber view

Perimembranous VSDTTE subcostal view

Perimembranous VSDTEE 4 Chamber view (0˚)

Perimembranous VSDDetailed assessment•Aneurysm?• How many defects?•Diameter of*infundibulum•Rim to aortic valve

Perimembranous VSDTEE LAX- wire through VSD

Additional defects?

Perimembranous VSD• Sometimes it is difficult to analyzethe margins and measure the size• Measurements in 2D and+ colourdoppler• Evaluation with 3D if available

Muscular VSDEcho evaluation• Size (measurements in different planes)• Number (single/multiple)• Location (apical, mid-muscular/highmuscular)• Associated defects (ASD/pulmonarystenosis/aortic coarctation/…)• Contra-indications for closure?

Muscular VSD• TTE viewsEcho evaluation- Apical 4 chamber view- Parasternal LAX and SAX views- Subcostal views

Muscular VSD• TEE viewsEcho evaluation- Mid-esophageal 4 chamber view (0˚)- Trans- gastric views- Mid-esophageal SAX views(30-35˚)

Muscular VSD2D TEE in 0 ˚ and 90 ˚

Muscular VSD2D TEE + colour: 4 Chamber view 0˚

Muscular VSDAspect of VSD →from LV and RV side

Muscular VSD3D TEE full volume: LV aspect of mid- muscular VSD + colour

Muscular VSDMid-muscular VSD after closure

Case44 y old man• Pre-diagnosed muscular VSD-Measurements: 6mm• 11/2010 implantation of a 6mmmuscular VSD occluder

Case44 y old manSizing: 14x8mmMigration of device→ size carefully!

Muscular VSDEcho evaluation• Usually easy to analyze the marginsand measure the size of the defect• Measurements of the defect in 2D andwith colour doppler• Measurements with 3D if available

Post Myocardial InfarctionVSDs

Acute Ventricular Septal Rupture• Medical treatment is difficult- 50-70% mortality within the first week- less than 10% survive month 1-3• Standard of therapy is surgery- Hospital mortality 10 to 60%- VSD re-occurs in 10-20%• Patch dehiscence• Development of a new VSD• Overlooked second VSD

Specific problems in post-MI VSD‘s• Atypical locations, deficient rim• Multiple defects• Large defects need immediatetreatment• Tissue weakening up to 2 w. post MI‣ We have the same problem as the surgeons‣Need for early treatment‣Better results with delayed treatment

Imaging in post- MI VSDs• Can be difficult→ unstable patient• TTE: poor imaging quality• TEE: inadequate alignment• Antero-apical defects difficult• MRI?

CaseInferior PI VSD• 82 y old man• Inferior MI 1998 + surgical VSD closure(patch, aneurysm resection)• EF 40%• 2005: large VSD (inferior location)• PAPs 70mmHg• Dyspnea Nyha III-IV• Qp:Qs 2.2• 1.9.2010- percutaneous VSD closure

CaseInferior PI- VSD20 mm Amplatzer ASD occluder- captured by trabeculae

CaseInferior PI VSD• 6/2010 (external evaluation):• Qp:Qs 1.16• Mild residual shunt adjacent to occluder• EF: 50%• PAPs 35 mmHg• Dyspnea Nyha II

Strategy in PI VSDs• Early treatment !!• Oversized devices (50-100%)

Take home message• Echocardiographic evaluation is mandatory inpatients with VSD for patient selection ( useof all imaging modalities)• Good imaging is crucial for planning ofintervention• Combined Echo and angio evaluation decideabout the closure technique and properdevice selection

Thank You

Percutaneous VSD closureComplications• Complete A-V block• Aortic and Tricuspid valve dysfunction• Malposition of device• Residual defectCarminati M et al.European H J 2007, 28: 2361Kenny D et al: Catheter Cardiovasc Interv 2009, 73:568-75

Adverse events after device closure ofperimembranous VSDs (n = 100 procedures)Holzer et al., Catheterization and Cardiovascular Interventions 2006; 68: 620-628

Carminati et al, CSI 2005, FrankfurtPost MI- VSDs (n=43)European VSD Registry• Reasons for in-hospital death- Multiorgan failure 15- Device embolisation 2- Tamponade 2- Leg ischemia 1- Tricuspid valve injury 1

Catheter Closure of Post MI VSDsnSuccess(%)Mortality(%)Chessa 2002 12 83 40Szkulnik 2003 7 71 20Goldstein 2004 4 75 25Holzer 2004 18 89 39Martinez 2007 5 100 20Ahmed 2007 5 4 40

Post-infarction VSD• 80% die within 4 weeks• 90% die within 6 month→ All need closure(surgical or percutaneous)

European VSD Register430 attempts in congenital VSDs, 409 devices implanted> 14 yrs34%

• Procedural mortality lowest it you waituntil tissues have healed (~ 3 weeks)• … but then > 90% of the patients havedied• → do it as soon as possible

Transcatheter closure ofperimembranous VSDYear Author N age (years) weight (kg)2006 Y.-C. Fu 35 median 7.7 median 25(1.2 – 54.4) (8.3 – 110)2006 R. Holzer 100 median 9 median 27.5(0.7 – 58) (7 – 121)2006 R. Pinto 20 median 10 median 32(7 – 21)2005 I. Masura 186 median 15.9 median 43(3 – 51) (12.5 – 77)not published T. Lê 86 mean 16.2 mean 32( Pfm coil ) (3 – 57) (12 – 71)

Surgical closure of VSD in 2079 patientsat GOH, London, from 1976 to 2001open columns = isolated VSDshaded columns = TOFAndersen et al., Ann Thorac Surg 2006; 82: 948-57

Transcatheter closure of pm VSD :amount of L-R shuntBeekmann, J Pediatr 2007; 150: 569-570

Incidence of complete heart block (CHB) andmortality after surgical closure of isolated VSDYear Author surgical period N CHB Mortality2001 Gaynor 1996 – 1999 172 0% 0.6%2003 Bol-Raap 1992 – 2001 188 1% 2%2006 Andersen 1976 – 2001 996 0.7% 1.5%

European Registry on Transcatheter VSD ClosurePerimembranous VSD ( n= 250 ) and CompleteHeart Block 13 (5%)4 (1.4%) Transient2 device implanted2 surgical device removal9 (3.6%) Permanent5 early (within 1 week)4 late (4-18 months)Courtesy Mario Carminati

Central Cardiac Audit Database in UK:Interventional closure ofperimembranous VSDNumber504540353025201510505 32000-20012001-200282002-2003452003-20042004-20052005-2006J Gibbs personal communication in: Sullivan et al., Heart 2007; 93: 284-286234

Andersen et al., Ann Thorac Surg 2006; 82: 948-57

Spontaneous VSD closureExponential decay curve of rate of closureKrovetz et al., Am J Cardiol 1998; 81: 100-101

Long-term outcome of adult patients (mean 30 y)with VSD considered not to require surgicalclosure during childhood• 118 prospectively followed pts• Study entry: 1993 - 1996• Events: death, endocarditis or surgery• Spontaneous closure in 6%Gabriel et al., JACC 2002; 39: 1066-71

Device Closure ofPerimembranous VSDFollow Up After Device Closure of Perimembranous VSDsHolzer et al., Catheterization and Cardiovascular Interventions 2006; 68: 620-628

European Registry on Transcatheter VSD ClosureComplete AV Block and Perimembranous VSD(Stepwise logistic regression analysis)%15%105< 5 y6-15 y> 15 y0cAVBCortesy Mario Carminati,

Surgery (post infarction• DisapointingVSD)• Early- tissues friable, patient unstable• Late (>3 weeks)tissues stronger,remodelling• Inferior location worse than anterior

Perimembranous VSD

VSD

European VSD Register430 attempts in congenital VSDs, 409 devices implanted• Perimembraneous 250• Muscular 119• Multiple 27• Residual post surgery 45

European VSD RegisterDevices implantedASD Amplatzer2%Starflex2%Coil2%2 devices4%PDA Amplatzer3%MembraneousAmplatzer51%MuscularAmplatzer36%Technical Success Rate 95 %

European VSD Register-430 attempts, 409 devices implanted(250 perimembr.,119 muscular,16 multiple congenital VSD)• Occluder Embolisation 5- Surgery (2), catheter retrieval (3)• Aortic valve insufficiency 14- Need for surgery (12)• Tricuspid valve insufficiency 27- No need for treatment• Transient or mild arrhythmia 102° AV block (1), LBBB (2), RBBB (3)• Complete AV-Block 17

Carminati et al, CSI 2005, FrankfurtPost MI- VSDs (n=43)European VSD Registry• Age 65 yrs (52-86)• VSD diameter 14 mm (6-24)• Acute phase 30• Non acute phase or post surgery 13• In hospital mortality- Acute phase 15/30 50%- Non acute phase 3/13 23%

Most frequently used devicesAmplatzer devices• ASD (4-36 mm)• VSD (4-18 mm)• Post-MI VSD (16-24 mm)

Most frequently used devicesperimembranous Amplatzer VSD occluder