| ObjectiveIntracristal or supracristal ventricular septal defects(VSD) is the least common type of VSD. Becasue of the surrounding structure is complicated, device closure of a intracristal or supracristal VSD is difficult to succeed in transcatheter approach. The aim of this study is to evaluate the feasibility, safety and efficacy of perventricular device closure of intracristal or supracristal ventricular septal defects through a parasternal approach.MethodsFrom May2009to May2012,49patients underwent periventricular device closure of intracristal or supracristal VSDs through a parasternal approach. Among them,27cases were intracristal ventricular septa] defects and22cases were supracristal ventricular septal defects,33cases were male and16cases were female. The age from0.3to53years and body weight from6to84kg. Seven of them were less than1year of age. Ten patients had mild degree of mitral regurgitation and6patients had mild degree of aortic regurgitation. One patient was a redo case with a supracristal residual shunt after repair of VSD. The supracristal VSD coexisted with a mirror image dextrocardia in1patient, with a patent ductus arteriosus in1patient. The inclusion criteria for device closure were as follows:the diagnostic criteria were that intracristal VSDs located at the12to1o’clock position and supracristal VSDs at the1to2o’clock position in the parasternal short-axis view (aortic valve level) on TTE; the maximum diameter of the intracristal VSD<8mm; the maximum diameter of the supracristal VSD<5mm; left to right shunt and no patients had aortic valve prolapse.After general anesthesia and intubation, patients were placed in a supine position. A complete TEE evaluation was performed to determine the maximum diameter of the defect, the defect rim under the aortic valve (the subaortic rim) and the rim from the pulmonary annulus to the defect. The device was selected and was screwed onto the delivery cable and pulled into the delivery sheath with the tip extruded out of the sheath. The closure device used in this study was a new modified double-disk occluder, based on the Amplatzer septal occluder. There were three types of devices used in this study:the concentric, the muscular and the eccentric occluder.A1.5cm to3cm parasternal incision was made in the left second or third intercostal space. Superficial tissues were opened with blunt dissection without entering into the pleural space. Exposure was optimized with a mini-retractor. The pericardium was incised and cradled after the thymus tissue was dissected. After anticoagulation with heparin, The puncture site was chosen at the right ventricular outflow tract down the pulmonary annulus and two parallel pursestring sutures of4-0or5-0Prolene. The delivery sheath loaded with the device was inserted into the right ventricular outflow tract. Normally, the sheath was towards the defect and perpendicular to the septum. Under TEE guidance, it was advanced through the defect into the left ventricular. Then the device was deployed and released. When an eccentric occluder was implanted, the side arm of the sheath was kept towards the apex. During deployment, the eccentric was advanced and opened without rotation. Then the platinum marker on the left disk would be pointing more or less towards the apex after deployment. If the left disk was not in a proper position, it would be adjusted by recapturing, rotation and redeployment to make the platinum marker far from the aortic valve.The device was inspected repeatedly by a push-pull maneuver and released only when its proper position was obtained and interference with the aortic, tricuspid and pulmonary valve had been excluded. Then the sheath and cable were withdrawn with the pursestring sutures snugly tied.All data are expressed as mean±. standard deviation and range. Intracardiac manipulation time is defined as the time the delivery sheath enters the RV until the delivery sheath and cable are withdrawn from the right ventricle. Intracardiac manipulation time and device size between the2groups was compared with the independent samples t test. Statistical comparisons of proportions were analyzed using either a chi-square or Fischer exact test. A probability (p) value of less than0.05was defined as statistical significance.ResultsIn the49patients, successful implantation of the device was achieved in47patients. Among them,26cases were intracristal ventricular septal defects and21cases were supracristal ventricular septal defects. The average diameter of the intracristal VSD was about4.4±1.7mm and the supracristal VSD was about2.7±0.9mm. The device size was7.0±2.3mm in the intracristal VSD group and4.8±1.1mm in the supracrista VSD group. The average intrcardiac manipulation time was17±16min. The patients were followed for a period of3months to2years, no device-related complications, such as device embolization, thrombosis, clinical hemolysis, or infective endocarditis, were found.ConclusionsThe minimally invasive technique of perventricular device closure of moddle supracristal or small intracristal ventricular septal defects is feasibility, safety and efficacy... |
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