Corresponding Author Information:
Dr. Satinder Sandhu MD
Professor of Pediatrics
Director, Pediatric Cardiac Cath Laboratory
Director, Adult Congenital Heart Disease
1611 NW 12th Avenue, NW Room109
Miami, Florida, 33136
Phone: 305-585-6683
Fax: 305-324-6012
Email: ssandhu3@med.miami.edu
Acknowledgements : The authors have no acknowledgments to
mention
In 1966 Drs. Rashkind & Miller set up the stage for transcatheter
therapy in congenital heart disease with the publication “Creation of
an atrial septal defect without thoracotomy: palliative approach to
complete transposition of the great arteries”(1). Since then
transcatheter therapy has become the main stay for repair and palliation
of select congenital heart defects resulting in improved outcomes. Over
the last two decades this has further expanded into hybrid procedures in
which the pediatric cardiothoracic surgeons, pediatric interventional
cardiologists and pediatric echocardiographers collaborate to perform
the procedure with the least invasive approach. An integral part of the
success of the hybrid procedures has been the role of transesophageal
echocardiography (TEE) in guiding the intervention without the need for
fluoroscopy thereby minimizing radiation exposure to the patient (2,3).
A meta-analysis of transcatheter device closure of peri-membranous
ventricular septal defects (Pm-VSDs) showed a high success rate of
device implantation with acceptable margin of safety and rate of
complications (4). In patients where transcatheter approach is
challenging an alternative approach with comparable results to the
transcatheter approach is the role of per ventricular closure with a
device through a minimally invasive incision without the need for
cardiopulmonary bypass (5).
Yu Jin et al (6) in their report focus on the value of intraprocedural
TEE to assist with device closure of the Pm-VSD through the
per-ventricular approach. The study is retrospective and includes 207
children with Pm-VSD who underwent device closure of the defect under
TEE guidance through a “ultra-minimal trans intercostal incision”. The
practical ease of the procedure and the benefits of using TEE
intra-procedurally were emphasized in this report. TEE was invaluable in
selecting the access site on the right ventricle, guiding the
positioning of the guidewire and the delivery sheath. The authors
concluded that the clarity of images obtained by TEE during this
procedure helped in navigating the anatomically difficult lesions,
device selection and positioning to prevent interference of the device
with the aortic and mitral valve. TEE also assessed the residual shunt
and stability of the device prior to and after release. In this report
the rate of successful device occlusion of the Pm-VSDs was 97.64%.
Overall this paper has demonstrated that TEE guided closure of a Pm-VSD
via minimally invasive device closure is a safe and effective procedure
with excellent outcomes when performed by an experienced imager. This
has been demonstrated in other studies where TEE was used to guide
similar procedures with good outcomes (7).
Per ventricular approach for closure of ventricular septal defects was
first described by Amin and colleagues in 1998 (8). This approach should
be considered in patients who are too small for transcatheter closure,
patients with limited vessel access and in patients with complex VSD
anatomy where device placement and device manuverability may be
challenging. The advantage of not requiring or shortening the time of
cardiopulmonary bypass is also an added value to the procedure. The
success of the procedure is dependent on intra-procedural imaging by TEE
in order to assess the anatomy of the defect and to mitigate the
potential complications of device closure by guiding the device delivery
and adjusting or repositioning the device if needed (9,10). The use of
TEE during the hybrid approach gives a wider field of view thereby
allowing access to the lesions where percutaneous delivery of the device
is restricted (11).
Hybrid procedures minimize the perioperative morbidity and improve the
long term outcomes in patients. This approach utilizes the strengths and
minimizes the limitations of the individual procedures. The future in
the treatment of congenital heart disease will be a collaborative effort
to get the best outcomes with the least invasive procedure.
References:
1. Rashkind W J, Miller W, Creation of an atrial septal defect without
thoracotomy: palliative approach to complete transposition of the great
arteries, JAMA (1966);196: pp. 991-992.
2. Van Der Velde ME, Perry SB. Transesophageal Echocardiography During
Interventional Catheterization in Congenital Heart Disease.
Echocardiography. 1997 Sep;14(5):513-528
3. Holzer R, de Giovanni J, Walsh KP, Tometzki A, Goh T, Hakim F, Zabal
C, de Lezo JS, Cao QL, Hijazi ZM. Transcatheter closure of
perimembranous ventricular septal defects using the amplatzer membranous
VSD occluder: immediate and midterm results of an international
registry. Catheter Cardiovasc Interv. 2006 Oct;68(4):620-8
4. Santhanam H, Yang L, Chen Z, Tai BC, Rajgor DD, Quek SC. A
meta-analysis of transcatheter device closure of perimembranous
ventricular septal defect. Int J Cardiol. 2018 Mar 1;254:75-83.
5. Li D, Zhou X, Li M, An Q. Comparisons of perventricular device
closure, conventional surgical repair, and transcatheter device closure
in patients with perimembranous ventricular septal defects: a network
meta-analysis. BMC Surg. 2020 May 26;20(1):115.
6. Yu Jin, Ye Jingjing, Zhang Newei, Yang Xiuzhen, Ma Lianglong, Qian
Jinging, Zhao Lei, Qiang Shu: Value of transesophageal echocardiography
in device closure of perimembranous ventricular septal defects in
children via ultra ‐minimal trans intercostal incision. In press
7. Ren C, Wu C, Pan Z, Li Y. Minimally invasive closure of transthoracic
ventricular septal defect: postoperative complications and risk factors.
J Cardiothorac Surg. 2021 Mar 19;16(1):30
8. Amin Z, Berry JM, Foker JE, Rocchini AP, Bass JL. Intraoperative
closure of muscular ventricular septal defect in a canine model and
application of the technique in a baby. J Thorac Cardiovasc
Surg. 1998 Jun;115(6):1374–6
9. Quansheng X, Silin P, Zhongyun Z, Youbao R, Shengde L, Qian C, Shuhua
D, Kefeng H, Zhixian J, Qin W. Minimally invasive perventricular device
closure of an isolated perimembranous ventricular septal defect with a
newly designed delivery system: preliminary experience. J Thorac
Cardiovasc Surg. 2009 Mar;137(3):556-9
10. Hu X, Peng B, Zhang Y, Ai F, Zheng J. Short-Term and Mid-Term
Results of Minimally Invasive Occlusion of Ventricular Septal Defects
via a Subaxillary Approach in a Single Center. Pediatr Cardiol. 2019
Jan;40(1):198-203
11. Michel-Behnke I, Ewert P, Koch A, Bertram H, Emmel M, Fischer G,
Gitter R, Kozlik-Feldman R, Motz R, Kitzmüller E, Kretschmar O;
Investigators of the Working Group Interventional Cardiology of the
German Association of Pediatric Cardiology. Device closure of
ventricular septal defects by hybrid procedures: a multicenter
retrospective study. Catheter Cardiovasc Interv. 2011 Feb
1;77(2):242-51.