Dear Editors,
A ventricular septal defect (VSD) is one or more holes in the wall that separates the right and
left ventricles of the heart. VSD is one of the most common congenital (present from birth) heart
defects. Many types of VSDs have been reported, including congenital VSDs, post-infarction VSDs
(11. Lee WY, Kim SJ, Kim KI, Lee JW, Kim HS, Lee HS, et al. Transatrial repair of
post-infarction posterior ventricular septal rupture. Korean J Thorac Cardiovasc Surg.
2011;44(2):186-8.), and post-traumatic VSDs (22. Xi EP, Zhu J, Zhu SB, Yin GL, Liu Y, Dong YQ, et al. Percutaneous closure of a
post-traumatic ventricular septal defect with a patent ductus arteriosus occlude. Clinics.
2012;67(11):1281-3, doi: 10.6061/clinics/2012(11)10.
https://doi.org/10.6061/clinics/2012(11)...
). Furthermore, there are four types of congenital VSDs; perimembranous VSD is the most
common, while outlet, atrioventricular, and muscular VSDs are less common (33. Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults. First of
two parts. N Engl J Med. 2000;342(4):256-63.). VSDs vary in size, number, and location within the interventricular septum, and
their clinical implications often depend on these factors.
Childhood mortality has continuously decreased in recent decades, and mortality has shifted
almost entirely to adulthood as a result of both conservative and surgical treatments (44. Greutmann M, Tobler D. Changing epidemiology and mortality in adult congenital
heart disease: looking into the future. Future Cardiol. 2012;8(2):171-7, doi:
10.2217/fca.12.6.
https://doi.org/10.2217/fca.12.6...
). Small congenital VSDs often close on their own as the heart
grows, and such patients may be treated conservatively (55. Samánek M. Children with congenital heart disease: probability of natural
survival. Pediatr. Cardiol. 1992;13(3):152-8.).
However, some patients may require surgical intervention. Percutaneous closure of VSDs has emerged
as a good alternative to address important and difficult cardiac surgical problems and prevent
issues related to cardiopulmonary bypass in selected patients (22. Xi EP, Zhu J, Zhu SB, Yin GL, Liu Y, Dong YQ, et al. Percutaneous closure of a
post-traumatic ventricular septal defect with a patent ductus arteriosus occlude. Clinics.
2012;67(11):1281-3, doi: 10.6061/clinics/2012(11)10.
https://doi.org/10.6061/clinics/2012(11)...
). The most important issue prior to percutaneous closure is to decide whether the defect
can be closed via a percutaneous approach and which device should be chosen.
Various devices that have been used for VSD closure have been reported in previous articles.
These devices include amplatzer® VSD Occluder, atrial septal defect (ASD) Occluder, and patent
ductus arteriosus (PDA) Occluder (22. Xi EP, Zhu J, Zhu SB, Yin GL, Liu Y, Dong YQ, et al. Percutaneous closure of a
post-traumatic ventricular septal defect with a patent ductus arteriosus occlude. Clinics.
2012;67(11):1281-3, doi: 10.6061/clinics/2012(11)10.
https://doi.org/10.6061/clinics/2012(11)...
,66. Fraisse A, Agnoletti G, Bonhoeffer P, Aggoun Y, Benkhalifa A, Piechaud JF.
Multicentre study of percutaneous closure of interventricular muscular defects with the aid of an
Amplatzer duct occluder prosthesis. Arch Mal Coeur Vaiss. 2004;97:484-8.,77. Suh WM, Kern MJ. Transcatheter closure of a traumatic VSD in an adult requiring
an ASD occluder device. Catheter Cardiovasc Interv. 2009;74(7):1120-5, doi:
10.1002/ccd.22141.
https://doi.org/10.1002/ccd.22141...
). However, there is no clear consensus
on device selection (88. Sait Demirkol, Sevket Balta, Mustafa Cakar, Ugur Kucuk. Which device should be
chosen for the percutaneous closure of post-traumatic ventricular septal defects? Clinics.
2013;68(3):423.). The investigators present their
experience with choosing devices for percutaneous VSD closure in this paper.
The main factor in choosing a device is the length of the occluder's waist. The Amplatzer
Muscular VSD Occluder and ASD Occluder are designed for congenital heart disease, and congenital
VSDs are uniformly straight and short. Therefore, the length of occluder's waist is limited to
approximately 4 mm. This device is also suitable for post-infarction VSDs and other straight and
short VSDs (66. Fraisse A, Agnoletti G, Bonhoeffer P, Aggoun Y, Benkhalifa A, Piechaud JF.
Multicentre study of percutaneous closure of interventricular muscular defects with the aid of an
Amplatzer duct occluder prosthesis. Arch Mal Coeur Vaiss. 2004;97:484-8.,77. Suh WM, Kern MJ. Transcatheter closure of a traumatic VSD in an adult requiring
an ASD occluder device. Catheter Cardiovasc Interv. 2009;74(7):1120-5, doi:
10.1002/ccd.22141.
https://doi.org/10.1002/ccd.22141...
).
Post-traumatic VSDs, as described by Xi EP, Zhu J, Zhu SB and their colleagues, are angled (22. Xi EP, Zhu J, Zhu SB, Yin GL, Liu Y, Dong YQ, et al. Percutaneous closure of a
post-traumatic ventricular septal defect with a patent ductus arteriosus occlude. Clinics.
2012;67(11):1281-3, doi: 10.6061/clinics/2012(11)10.
https://doi.org/10.6061/clinics/2012(11)...
). The length of this type of VSD is typically longer, frequently
more than 9 mm. Therefore, the Amplatzer Muscular VSD Occluder and ASD Occluder are not
appropriate.
The use of the PDA Occluder for post-traumatic VSD closure suggested a new way of approaching
treatment for the closure of different types of VSDs and provided a new standard for the design of
occlusion devices. The use of the PDA Occluder for VSD closure has several advantages compared with
the Amplatzer Muscular VSD Occluder and the ASD Occluder. First, if the right-sided opening of the
VSD is near the right ventricular outflow tract, the right disc may obstruct the ventricular outflow
tract when VSD or ASD Occluders are used. The PDA Occluder cannot cause ventricular outflow tract
obstruction because it only has a left disc; furthermore, this single disc reduces the cost of the
closure device. In addition, the metal waist of a PDA Occluder is both more flexible and softer than
other occluder implants, so it is more easily released and molded. The implant also moves in
synchrony with the heartbeat. Fatigue damage to an occluder's metal material (99. Bafaloukas N, Birch M, Buchholz N. Rationale and feasibility study of a
mechanical model for the testing of material fatigue in metal ureteral stents. J Endourol.
2008;22(2):389-92, doi: 10.1089/end.2006.9862.
https://doi.org/10.1089/end.2006.9862...
) occurs under the action of the dynamic load, and an
implant's main cause of failure is fatigue rupture. This type of rupture is more likely to
occur in occluders that have two discs and a very narrow waist, which are more likely to experience
fatigue rupture because of the loads on the two discs.
Based on our limited experience and a lower observed morbidity rate, our view is detailed below. The use of PDA Occluder devices for percutaneous closure of post-traumatic VSDs is feasible, safe and effective. This method could allow all types of VSDs to be closed via a percutaneous approach. Furthermore, the use of a PDA Occluder provides a new standard for the design of occluder devices. However, in the absence of larger studies comparing surgical options, observational management and skillful clinical intervention, and most clinicians have more clinical experience using these devices, we suggest continuing to use a VSD Occluder or ASD Occluder in general VSD cases for routine repair for a longer experience on clinical application. But due to different types of VSD, different options of the device should be taken to solve them.
References
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1Lee WY, Kim SJ, Kim KI, Lee JW, Kim HS, Lee HS, et al. Transatrial repair of post-infarction posterior ventricular septal rupture. Korean J Thorac Cardiovasc Surg. 2011;44(2):186-8.
-
2Xi EP, Zhu J, Zhu SB, Yin GL, Liu Y, Dong YQ, et al. Percutaneous closure of a post-traumatic ventricular septal defect with a patent ductus arteriosus occlude. Clinics. 2012;67(11):1281-3, doi: 10.6061/clinics/2012(11)10.
-
3Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults. First of two parts. N Engl J Med. 2000;342(4):256-63.
-
4Greutmann M, Tobler D. Changing epidemiology and mortality in adult congenital heart disease: looking into the future. Future Cardiol. 2012;8(2):171-7, doi: 10.2217/fca.12.6.
-
5Samánek M. Children with congenital heart disease: probability of natural survival. Pediatr. Cardiol. 1992;13(3):152-8.
-
6Fraisse A, Agnoletti G, Bonhoeffer P, Aggoun Y, Benkhalifa A, Piechaud JF. Multicentre study of percutaneous closure of interventricular muscular defects with the aid of an Amplatzer duct occluder prosthesis. Arch Mal Coeur Vaiss. 2004;97:484-8.
-
7Suh WM, Kern MJ. Transcatheter closure of a traumatic VSD in an adult requiring an ASD occluder device. Catheter Cardiovasc Interv. 2009;74(7):1120-5, doi: 10.1002/ccd.22141.
-
8Sait Demirkol, Sevket Balta, Mustafa Cakar, Ugur Kucuk. Which device should be chosen for the percutaneous closure of post-traumatic ventricular septal defects? Clinics. 2013;68(3):423.
-
9Bafaloukas N, Birch M, Buchholz N. Rationale and feasibility study of a mechanical model for the testing of material fatigue in metal ureteral stents. J Endourol. 2008;22(2):389-92, doi: 10.1089/end.2006.9862.
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No potential conflict of interest was reported.
Publication Dates
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Publication in this collection
Feb 2014