Clinical Study Of Minimally Invasive Transcatheter Closure Of Juxta-arterial Ventricular Septal Defect Without Cardiopulmonary Bypass

Part One: The clinical application of minimally transthoracic device closure of juxta-arterial ventricular septal defect under transesophageal echocardiography guidanceObjection: In recent years,minimally invasive transthoracic device closure has been introduced as an alternative treatment option for selected patients with juxta-arterial ventricular septal defects(VSDs).The purpose of this study is to evaluate the safety and efficacy of using device closure in selected patients.Methods: Between January 2008 and December 2014,25 patients with juxta-arterial VSDs who met the inclusion criteria were enrolled in this study.The inclusion criterion was: confirmed diagnosis of juxta-arterial VSD by echocardiography.The exclusion criteria were:(1)patient less than 3 months old;(2)echocardiogram-confirmed obvious prolapse of the aortic valve(AP)greater than mild grade;(3)echocardiogram-confirmed obvious aortic regurgitation(AR)greater than mild grade;(4)VSD size larger than 8 mm;(5)other associated congenital heart defect that requires surgery under CPB;and(6)confirmed severe pulmonary hypertension.Perventricular closure was attempted using minimally invasive transthoracic device closure without cardiopulmonary bypass under general anesthesia and transesophageal echocardiography guidance.A 3-4-cm lower partial median sternotomy and a 2-3-cm left anterior mini-thoracotomy were used to facilitate the surgery.In our center,left anterior mini-thoracotomy approach was selected with VSD diameter less than 6 mm.With VSD diameter equal to or more than 6 mm we prefered to choose lower partial median sternotomy which could be convert easily to standard median sternotomy when transventricular VSD closure failed.A small pericardiotomy was performed and the pericardium was cradled to expose the free wall of the right ventricle.The puncture site was determined under TEE guidance.A purse-string suture was done at the puncture site,the right ventricle was punctured with a 18-G trocar,the needle was removed,and a 0.035-inch guide wire was passed through the puncture and the defect into the left ventricle.The trocar was removed and a delivery sheath was advanced on the wire to the left ventricle.The occluder was fixed on a delivery cable,which was introduced in the delivery sheath.The left ventricle disk was deployed and the cable was pulled until the left ventricle disk was pulled on the septum.The occluder was then completely deployed,as verified by TEE.TEE was then used to assess the presence of any undesirable changes of aortic morphology,left and right ventricular outflow tract obstruction,residual shunt,device malposition,and device-induced new regurgitation of the aortic,mitral,pulmonary,or tricuspid valves.Nominal variables were expressed aspercentages.Continuous variables were expressed as mean±SD or median(range).SPSS 16.0 for windows(SPSS Inc.,Chicago,IL,USA)was used for statistical analysis.Results: Minimally invasive transthoracic device closure was successfully performed in 23 patients(92%)with a median age of 18 months.Device closure failed in 2 patients(one with aortic regurgitation(AR)and one with right ventricular outflow tract stenosis);they were converted to open surgery.No severe complications(device shift,significant arrhythmia,ventricular outflow tract obstruction,or obvious valve regurgitation)were observed.There was no closure-associated valve regurgitation.Conclusion: In select patients,minimally invasive transthoracic device closure of juxtaarterial VSDs appears to be safe and effective.Part Two: Transthoracic device closure of juxta-arterial ventricular septal defects: Mid-term and long-term follow-up resultsObjection: The minimally invasive transthoracic device closure of the VSD especially juxta-arterial VSD is a new minimally invasive surgical techniques,its short-term clinical results are very satisfactory.But its further popularization and application,must carry out system,the science of follow-up,so as to objectively evaluate the long-term safety and efficacy,which will provide a scientific basis for further clinical application.Methods: Follow-up object for the minimally invasive thoracic plugging success of 23 patients.For follow-up of patients develop detailed follow-up plan: 1,3,6 months postoperatively,later every year back to the hospital to review,electrocardiogram,echocardiography and X-ray line plain chest radiography,etc.With detailed assessment of different types and sizes of the VSD occluder in postoperative cardiac function,structure,the influence of electrophysiology.In addition,creating a database of detailed,strong operability of preoperative,intraoperative and postoperative patient data for comparison and analysis of the system.The application of SPSS 16.0 statistical software for statistical analysis.Accord with normal distribution of measurement data with mean±standard deviation((?)±SD)said that do not conform to the normal distribution of measurement data with median and range data,said count data to the number(percentage).Results: By 2016,6 from the date of writing this paper,the follow-up rate was 100%.The follow-up process patients had no serious complications,preoperative there were no obvious postoperative cardiac ultrasound in patients with mitral valve reflux,right ventricular outflow tract,left ventricular outflow tract stenosis,cardiac morphology and function not seen obvious abnormity,block umbrella shiftless.Cardiac ultrasonography can display block umbrella although close to the aortic valve and pulmonary valve,but for the aortic valve and pulmonary valve not significantly affect the morphology and function.And over time the postoperative patients with aortic valve prolapse,aortic regurgitation,pulmonary valve regurgitation and tricuspid regurgitation in how can reduce the trend.Conclusions: The minimally invasive transthoracic device closure successfully found no serious complications in patients with long-term follow-up and closure of the aortic valve and pulmonary valve without adverse effects,and longer duration of follow-up of valvular regurgitation in varying degrees.For selective patients with juxta-arterial ventricular septal defect,the minimally invasive transthoracic device closure treatment is safe and effective long-term.Part Three: Preliminary study of computer reconstruction and virtual endoscopy techniques based on enhanced CT of juxta-arterial ventricular septal defectsObjection: For the diagnosis and preoperative evaluation of ventricular septal defect currently rely mainly on cardiac ultrasound,with the requirement of precision medical,the spatial resolution of the cardiac ultrasound can not meet the clinical need.On the basis of heart enhanced CT of juxta-arterial ventricular septal defect under preliminary study computer reconstruction and virtual endoscopy technology,explore can show juxtaarterial ventricular septal defect space structure more accurate inspection method.Methods: To choose a patients of juxta-arterial ventricular septal defect without other cardiac malformation.Imaging equipment and imaging:using Simens definition flash scan,heart enhanced CT examination of the patients.Scan range: from the apex to the bottom of heart,heart switch control range from bronchus divides into the bottom of the heart.Used in the process of scanning the retrospective heart switch control,using the chest scanning sequence.Image post-processing: after the scan,thin layer of primary data reconstruction,layer thickness,layer spacing of 0.75 mm and 0.6 mm respectively,transmit the data from to Syngo Acquisition Workplace post-processing workstation.Results: Cardiac enhanced CT two-dimensional screenshots can clearly show ventricular septal defect,ventricular septal edge,aortic valve,pulmonary valve,aortic sinus and the pulmonary artery and ventricular septal defect structure around it.But in the 3D reconstruction of clarity declined obviously,it is difficult to show ventricular septal defect and surrounding tissues.Virtual endoscopy technology structure of ventricular septal defect in general can be viewed from various angles,stereo sense is stronger,more close to the object that we see in the operation.Conclusion: Computer reconstruction based on Enhanced CT of juxta-arterial ventricular septal defect can be displayed the structure of ventricular septal defect.Looking forward to stronger and more specialized post-processing software clearly display the threedimensional structure of ventricular septal defect,3D printing technology for the precise treatment of juxta-arterial ventricular septal defect would play a key role.