Korean Circ J.  2023 Mar;53(3):134-150. 10.4070/kcj.2022.0336.

Percutaneous Transcatheter Closure of Congenital Ventricular Septal Defects

• Song J

• KMID: 2540392
• DOI: http://doi.org/10.4070/kcj.2022.0336

Abstract

Ventricular septal defects (VSDs) are the most common kind of congenital heart disease and, if indicated, surgical closure has been accepted as a gold-standard treatment. However, as lessinvasive methods are preferred, percutaneous device closure has been developed. After the first VSD closure was performed percutaneously by Lock in 1988, both techniques and devices have developed consistently. A perventricular approach for closure of muscular VSD in small patients and the closure of perimembranous VSD using off-label devices are key remarkable developments. Even though the Amplatzer membranous VSD occluder (Abbott) could not be approved for use due to the high complete atrioventricular conduction block rate, other new devices have shown good results for closure of perimembranous VSDs. However, the transcatheter technique is slightly complicated to perform, and concerns about conduction problems after VSD closure with devices remain. There have been a few reports demonstrating successful closure of subarterial-type VSDs with Amplatzer devices, but long-term issues involving aortic valve damage have not been explored yet. In conclusion, transcatheter VSD closure should be accepted as being as effective and safe as surgery but should only be performed by experienced persons and in specialized institutes because the procedure is complex and requires different techniques. To avoid serious complications, identifying appropriate patient candidates for device closure before the procedure is very important.

Keyword

Ventricular septal defect; Occluder device; Atrioventricular block; Aortic regurgitation

Figure

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  Figure 1 Approaches for VSD closure include a retrograde approach from the femoral artery (A) and an antegrade approach from the femoral vein (B).VSD = ventricular septal defect.

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  Figure 2 Entanglement of the tricuspid chordae by an arteriovenous loop.

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  Figure 3 Perventricular closure of muscular VSD. A direct puncture of the right ventricle free wall (A) and sheath insertion over the defect (B) are followed by device preparation (C) and implantation (D). After the implantation, the puncture site should be sutured (E).VSD = ventricular septal defect.

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  Figure 4 Trans-esophageal echocardiography guidance for perventricular closure of muscular VSD. Conformation of the defect and puncture site (A, B) leads to the puncture needle passing through the defect (C) and device deployment partially inside the left ventricle (D). Echocardiography confirms a secure position of the device (E) and complete defect closure (F).VSD = ventricular septal defect.

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  Figure 5 The asymmetric shape of the Amplatzer membranous VSD occluder (A), which is designed to sit across the defect without distorting the aortic valve. A left ventricular angiogram demonstrates complete closure of the defect (B), and a lack of aortic valve impingement is confirmed by an aortic angiogram (C). A radiopaque marker on the left ventricular disk helped to confirm appropriate device positioning (courtesy of Abbott, Inc., Chicago, IL, USA).Figure is adapted from Bass et al.55) with permission.VSD = ventricular septal defect.

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  Figure 6 Amplatzer devices for VSD closure. The Amplatzer muscular VSD occluder (A), ADO type I (B), and ADO type II (C).ADO = Amplatzer duct occluder; VSD = ventricular septal defect.

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  Figure 7 New Amplatzer perimembranous VSD occluders include a symmetrical type (A) and an asymmetrical type (B). The white arrow (A) indicates the 3-mm superior rim of the symmetrical device. The black arrow (B) indicates the 1-mm superior rim of the asymmetrical device. The curvature of the left side wing can match the left ventricle outflow tract.VSD = ventricular septal defect.

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  Figure 8 VSD on computed tomography. The diameter of the VSD (white arrow) can be measured clearly on a four-chamber image (A), and the VSD (thick black arrow) is distant enough from the aortic valve (thin black arrow) (B).VSD = ventricular septal defect.

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  Figure 9 The Cocoon device closes the defect by its positioning in the aneurysm (A) and occluding directly from the left ventricular hole (B).

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  Figure 10 Nine days after transcatheter closure of perimembranous VSD in a 25-year-old patient, an idio-junctional accelerated rhythm appeared. Normal sinus rhythm was recovered after steroid treatment.VSD = ventricular septal defect.

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  Figure 11 Other devices available for VSD closure include the Cocoon VSD occluder aneurysmal type (A), Nit-Occlud® VSD coil (B), and KONAR-Multifunctional™ VSD occluder (C).VSD = ventricular septal defect.

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