Early outcomes of a triple-branched stent graft implantation in elderly patients with acute type a aortic dissection.

PURPOSE: Older patients with acute type A aortic dissection (ATAAD) have higher risk of mortality than that of younger patients when a total arch reconstruction (TAR) is required. Triple-branched stent graft (TBSG) implantation is a novel technique for TAR. However, early outcomes of a TBSG implantation in older patients have not been reported. This study aimed to evaluate the early outcomes of the TBSG technique in older patients with ATAAD. METHODS: From February 2015 to December 2020, 640 patients who simultaneously underwent an emergent open aortic surgery and TBSG implantation for ATAAD were enrolled in this study. They were categorized into the younger (age ≤ 70 years old, n = 573) and older groups (age > 70 years, n = 67). Clinical data of all patients were retrospectively reviewed. RESULT: The mean ages of the patients in the younger and older groups were 45.3 ± 9.6 years old and 73.5 ± 3.0 years old, respectively. Preoperative characteristics were similar between the two groups, except for weight and incidence of moderate or greater aortic regurgitation, which were lower in the older group than those in the younger group. Surgical procedure and duration (i.e., duration for cardiopulmonary bypass, aortic cross-clamp, selected cerebral perfusion, and total circulation arrest) were comparable between the two groups (p > 0.05). Patients in the older group had higher incidence of dialysis for acute kidney injury and longer ICU stay compared with those in the younger group. However, the incidences of 30-day mortality (5.1% in younger group vs. 7.5% in older group, p = 0.407) and other major complications (i.e., neurological adverse events) were similar between the two groups. CONCLUSION: TBSG implantation for ATAAD resulted in an acceptable mortality rate in patients above 70 years old, thus, it could be a feasible surgical procedure to perform in older patients with ATAAD when a TAR is required.

A new procedure for elimination of atrial fibrillation associated with mitral valve disease: a proof-of-concept study.

BACKGROUND: Left atrial enlargement and fibrosis have been linked to the pathogenesis of atrial fibrillation (AF). The authors aimed to introduce a novel concept and develop a new procedure for AF treatment based on these characteristics. METHODS: The study included three stages. The first stage was a descriptive study to clarify the characteristics of the left atrial enlargement and fibrosis' distribution in patients with mitral valve disease and long-standing persistent AF. Based on these characteristics, the authors introduced a novel concept for AF treatment, and then translated it into a new procedure. The second stage was a proof-of-concept study with this new procedure. The third stage was a comparative effectiveness research to compare the clinical outcomes between patients with this new procedure and those who received Cox-Maze IV treatment. RESULTS: Based on the nonuniform fashion of left atrial enlargement and fibrosis' distribution, the authors introduced a novel concept: reconstructing a left atrium with appropriate geometry and uniform fibrosis' distribution for proper cardiac conduction, and translated it into a new procedure: left atrial geometric volume reduction combined with left appendage base closure. As compared to the Cox-Maze IV procedure, the new procedure spent significantly shorter total surgery time, cardiopulmonary bypass time, and aortic cross-clamp time ( P <0.001). Besides, the new procedure was related to a shorter ICU stay period (odd ratio (OR)=0.45, 95% CI=0.26-0.78), lower costs (OR=0.15, 95% CI=0.08-0.29), and a higher rate of A wave of transmitral and transtricuspid flow reappearance (OR=1.76, 95% CI=1.02-3.04). CONCLUSIONS: The new procedure is safe and effective for eliminating AF associated with mitral valve disease.

Benefits of sacubitril/valsartan use in patients with chronic heart failure after cardiac valve surgery: a single-center retrospective study.

OBJECTIVES: To evaluate the efficacy of sacubitril/valsartan for the treatment of patients with chronic heart failure (CHF) after cardiac valve surgery (CVS). METHODS: Data were collected from 259 patients who underwent CVS due to valvular heart disease and were admitted to the hospital with CHF from January 2018 to December 2020. The patients were divided into Group A (treatment with sacubitril/valsartan) and Group B (treatment without sacubitril/valsartan). The duration of treatment and follow-up was 6 months. The two groups' prior and clinical characteristics, post-treatment data, mortality, and follow-up data were analysed. RESULTS: The effective rate of Group A was higher than that of Group B (82.56% versus 65.52%, P < 0.05). The left ventricular ejection fraction (LVEF, %) was improved in both groups. The final value minus the initial value was (11.14 ± 10.16 versus 7.15 ± 11.18, P = 0.004). The left ventricular end-diastolic/-systolic diameter (LVEDD/LVESD, mm) in Group A decreased more than in Group B. The final value minus the initial value was (-3.58 ± 9.21 versus - 0.27 ± 14.44, P = 0.026; -4.21 ± 8.15 versus - 1.14 ± 12.12, P = 0.016, respectively). Both groups decreased the N-terminal prohormone of B-type natriuretic peptide (NT-proBNP, pg/ml). The final value minus initial value was [-902.0(-2226.0, -269.5) versus - 535.0(-1738, -7.0), P = 0.029]. The systolic and diastolic blood pressure (SBP/DBP, mmHg) in Group A decreased more than in Group B. The final value minus the initial value was (-13.13 ± 23.98 versus - 1.81 ± 10.89, P < 0.001; -8.28 ± 17.79 versus - 2.37 ± 11.41, P = 0.005, respectively). Liver and renal insufficiency, hyperkalaemia, symptomatic hypotension, angioedema, and acute heart failure had no statistical differences between the two groups. CONCLUSIONS: Sacubitril/valsartan can effectively improve the cardiac function of patients with CHF after CVS by increasing LVEF and reducing LVEDD, LVESD, NT-proBNP, and BP, with good safety.

Triple-Branched Stent Graft Implantation for Acute Non-A-non-B Aortic Dissection.

BACKGROUND: The optimal treatment for acute non-A-non-B aortic dissection remains controversial. Triple-branched stent graft (TBSG) implantation has been used to treat acute type A aortic dissection. This study aimed to evaluate the safety and efficacy of TBSG as a treatment for acute non-A-non-B aortic dissection. METHODS: Fifty patients with non-A-non-B dissection received TBSG implantation in our center between January 2014 and December 2019. Early mortality, morbidity, and dissected aorta remodeling during follow-up were calculated. RESULTS: There were no deaths in-hospital or within 30 days. Postoperative complications included pneumonia (n = 12), acute kidney injury (n = 6; preoperative renal malperfusion, n = 4), transient cerebral injury (n = 6; preoperative cerebral malperfusion, n = 4), pleural effusion (n = 4), and pericardial effusion (n = 2). During follow-up, 1 patient experienced a stroke, and 2 patients required secondary interventional therapy for residual dissection below the level of the TBSG. All implanted TBSGs had good positioning, and all sidearm stent graft grafts were fully patent. No retrograde aortic dissection or type I endoleak was detected. CONCLUSIONS: TBSG implantation for acute non-A-non-B aortic dissection had a low incidence of mortality and morbidity, featuring good remodeling of the dissected aortic wall during follow-up. The early outcomes of this technique were satisfactory.

Mesenchymal stem cell secretions improve donor heart function following ex vivo cold storage.

OBJECTIVES: Heart transplantation is the gold standard of treatments for end-stage heart failure, but its use is limited by extreme shortage of donor organs. The time "window" between procurement and transplantation sets the stage for myocardial ischemia/reperfusion injury, which constrains the maximal storage time and lowers use of donor organs. Given mesenchymal stem cell (MSC)-derived paracrine protection, we aimed to evaluate the efficacy of MSC-conditioned medium (CM) and extracellular vesicles (EVs) when added to ex vivo preservation solution on ameliorating ischemia/reperfusion-induced myocardial damage in donor hearts. METHODS: Mouse donor hearts were stored at 0°C-4°C of <1-hour cold ischemia (<1hr-I), 6hr-I + vehicle, 6hr-I + MSC-CM, 6hr-I + MSC-EVs, and 6hr-I + MSC-CM from MSCs treated with exosome release inhibitor. The hearts were then heterotopically implanted into recipient mice. At 24 hours postsurgery, myocardial function was evaluated. Heart tissue was collected for analysis of histology, apoptotic cell death, microRNA (miR)-199a-3p expression, and myocardial cytokine production. RESULTS: Six-hour cold ischemia significantly impaired myocardial function, increased cell death, and reduced miR-199a-3p in implanted hearts versus <1hr-I. MSC-CM or MSC-EVs in preservation solution reversed the detrimental effects of prolong cold ischemia on donor hearts. Exosome-depleted MSC-CM partially abolished MSC secretome-mediated cardioprotection in implanted hearts. MiR-199a-3p was highly enriched in MSC-EVs. MSC-CM and MSC-EVs increased cold ischemia-downregulated miR-199a-3p in donor hearts, whereas exosome-depletion neutralized this effect. CONCLUSIONS: MSC-CM and MSC-EVs confer improved myocardial preservation in donor hearts during prolonged cold static storage and MSC-EVs can be used for intercellular transport of miRNAs in heart transplantation.

Severe Bronchospasm During Aortic Surgery for Type A Aortic Dissection.

Severe bronchospasm during cardiopulmonary bypass is an unusual but potentially fatal event. No literature previously has reported such an event observed during surgery for type A aortic dissection. Herein, we report on a case of severe bronchospasm following cardiopulmonary bypass, during aortic surgery for type A aortic dissection. Bronchospasm did not respond to any conventional therapy, necessitating extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation thus serves as an alternative and effective therapy for refractory bronchospasm.

Balloon Valvuloplasty via the Pulmonary Artery Trunk for Treating Neonates With Severe Pulmonary Valve Disease.

BACKGROUND: Percutaneous balloon pulmonary valvuloplasty has proven to be a standard of care for neonates with severe pulmonary valve disease. However, the peripheral vessel injury, tricuspid chordae tendineae rupture, and cardiac tamponade could occur. Recently, we performed balloon valvuloplasty through pulmonary artery trunk. To date, the obtained outcome was promising. METHODS: Between January 2018 and December 2018, three neonates with critical pulmonary stenosis and two with membranous pulmonary atresia with intact ventricular septum were enrolled in our center. Balloon valvuloplasty through pulmonary artery trunk was performed in all patients. A 2-cm parasternal incision was made in the left third intercostal space. A guidewire was used to advance or perforate the pulmonary valve from the pulmonary artery trunk into the right ventricle, followed by balloon dilation of the valve. RESULTS: The procedure was successful in all patients. The oxygen saturation increased immediately after the balloon dilation, while the right ventricular systolic pressure and the gradient across the pulmonary valve decreased. No severe complications occurred. CONCLUSIONS: Balloon valvuloplasty through the pulmonary artery trunk is a safe and feasible alternative procedure. Thus, it could serve as a supplementary choice for treating severe pulmonary valve disease.

Efficacy, safety, and long-term survival of concomitant valve replacement and bipolar radiofrequency ablation in patients aged 70 years and older: a comparative study with propensity score matching from a single-Centre.

BACKGROUND: Concomitant bipolar radiofrequency ablation and valve replacement in the elderly remains controversial. In the current study, we aimed to compare the outcomes of concomitant valve replacement and bipolar radiofrequency ablation with valve replacement alone in elderly patients with atrial fibrillation (AF). METHODS: This was a retrospective study of patients aged ≥70 years who underwent valve replacement with or without bipolar radiofrequency ablation in a single-centre between January 2006 and March 2015. The early postoperative results and long-term clinical outcomes were compared after propensity score matching. RESULTS: A total of 34 pairs of patients (73.94 ± 2.64 years old; 34 in the AF with ablation group and 34 in the AF without ablation group) were enrolled in the propensity score matching analysis. There were no significant differences between the two matched groups in terms of surgical mortality (5.88% vs. 2.94%, P = 0.555) and major postoperative morbidity. Kaplan-Meier analysis revealed a significantly better overall survival in the AF with ablation group compared to the AF without ablation group (P = 0.009). Cumulative incidence curves showed a lower incidence of cardiovascular death in the AF with ablation group (P = 0.025, Gray's test). Patients in the AF with ablation group had a reduced incidence of stroke compared to patients in the AF with ablation group (P = 0.009, Gray's test). The freedom from AF after 5 years was 58.0% in the AF with ablation group and 3.0% in the AF without ablation group. CONCLUSIONS: The addition of bipolar radiofrequency ablation is a safe and feasible procedure, even in patients aged ≥70 years, with a better long-term survival and a reduced incidence of stroke compared to valve replacement alone. These findings suggest that bipolar radiofrequency ablation should always be considered as a concomitant procedure for elderly patients with AF who require cardiac surgery. However, a large-scale, prospective, multi-centre, randomized study should be performed in the future to fully validate our findings.

A modified axillo-femoral perfusion for acute type a aortic dissection accompanied with lower limb malperfusion.

BACKGROUND: Lower limb malperfusion accompanied with acute type A dissection (AAD) is reported to be an independent predictor for mortality. Timely treatment is required. However, staged approach to restore the perfusion of the ischemic leg before aortic repair has a continuously increase risk of aortic rupture. Aortic repair under isolated axillary artery perfusion also has the risk of prolonging leg ischemia. Here we introduce our experience in performing axillo-femoral perfusion, which is supposed to bring benefits for treating lower limb malperfuison. METHODS: Thirty patients who suffered AAD accompanied by lower limb ischemia enrolled in our study. All patients received aortic repair as soon as possible using the modified axillo-femoral perfusion approach. The cardiopulmonary bypass and cooling started with the right axillary artery perfusion. Then the femoral artery of the ischemic side was exposed and sewn to a graft connected with another inflow cannula. The rectal temperature was about 31 °C when the femoral perfusion started. The perfusion of the ischemic legs preoperative was estimated after the surgery by the clinical signs, the saturation of the distal-limb, and computed tomography scan. RESULTS: Twenty-eight patients got good perfusion of the lower body after the surgery. Two patients received femoral-femoral artery bypass immediately after surgery because of the thrombosis in the right common iliac artery, without further injury. No peripheral vessels damage occurred, and no compartment fasciotomy or amputation needed. One patient died for the sepsis and the subsequent multi organ failure 28 days postoperative. CONCLUSIONS: The modified axllio-femoral perfusion could restore the lower limbs' perfusion simultaneously during the aortic surgery without neither delaying dissection repair nor prolonging the ischemic time. It is a simple, but safe and effective technique.

Metabolic syndrome increases operative mortality in patients with impaired left ventricular systolic function who undergo coronary artery bypass grafting: a retrospective observational study.

BACKGROUND: Metabolic syndrome (MetS) is a prevalent risk factor for coronary artery disease progression. Past studies have shown that MetS and its components tends to increase mortality after coronary artery bypass grafting (CABG), but data on the impact of MetS on postoperative outcome in patients with a left ventricular (LV) ejection fraction (EF) < 50% are still lacking. METHODS: Out of 2300 patients who underwent CABG between 2008 and 2018 in our center, 190 patients were identified as having impaired LV systolic function (EF < 50%). The patients were divided into two groups: those with MetS (n = 87, 45.8%) and those without MetS (n = 103, 54.2%). The influence of MetS on postoperative mortality and major complications was investigated. RESULTS: Postoperative mortality occurred in 12.6% of patients with MetS and in 3.9% of patients without MetS (p < 0.05). Multivariate analysis showed that patients with MetS had a significantly greater risk of mortality compared with patients without MetS (relative risk 7.23, p < 0.05). After adjustment for other risk factors, the risk of mortality was increased 6.47-fold [95% confidence interval (CI):1.25-33.6; p < 0.05] in patients with MetS and diabetes and 5.4-fold (95% CI: 1.12-29.7; p < 0.05) in patients with MetS and without diabetes, whereas it was not significantly increased in patients with diabetes and without MetS. CONCLUSIONS: MetS is an important predictor of increased mortality in patients with LVEF<50% who undergo CABG. The components of MetS have synergistic effect in postoperative mortality. Multifactorial intervention in MetS is required to improve surgical efficacy in these patients.

A clinical study of thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty, with domestically manufactured pipeline products for cardiopulmonary bypass.

OBJECTIVE: To discuss the feasibility and experience of treating valvular heart diseases with thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty, with domestically manufactured pipeline products for cardiopulmonary bypass. METHODS: A total of 135 patients with valvular heart disease were admitted to our hospital between January 2011 and January 2013. They received thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty, with domestically manufactured pipeline products. A cardiopulmonary bypass with domestically-manufactured pipeline products was established during the surgery. The procedure was accomplished with the assistance of thoracoscopy through a small incision in the right chest wall. RESULTS: All 135 patients underwent a successful surgery, and were followed up for the duration of half a year to two years. None of them displayed any evidence of complications. Our procedure had the advantage of fewer complications and a significantly shortened time period for the patient care and hospitalization. As opposed to imported pipeline products for cardiopulmonary bypass, our procedure had the advantage of similar clinical results at a lower cost. CONCLUSIONS: Thoracoscopy-assisted mitral valve replacement concomitant with tricuspid valvuloplasty was proved to be a safe and effective method for cardiopulmonary bypass, with the use of domestically manufactured pipeline products.

Total arch repair for acute type A aortic dissection with open placement of a modified triple-branched stent graft and the arch open technique.

BACKGROUND: In total arch repair with open placement of a triple-branched stent graft for acute type A aortic dissection, the diameters of the native arch vessels and the distances between 2 neighboring arch vessels did not always match the available sizes of the triple-branched stent grafts, and insertion of the triple-branched stent graft through the distal ascending aortic incision was not easy in some cases. To reduce those two problems, we modified the triple-branched stent graft and developed the arch open technique. METHODS AND RESULTS: Total arch repair with open placement of a modified triple-branched stent graft and the arch open technique was performed in 25 consecutive patients with acute type A aortic dissection. There was 1 surgical death. Most survivors had an uneventful postoperative course. All implanted stents were in a good position and wide expansion, there was no space or blood flow surrounding the stent graft. Complete thrombus obliteration of the false lumen was found around the modified triple-branched stent graft in all survivors and at the diaphragmatic level in 20 of 24 patients. CONCLUSIONS: The modified triple-branched stent graft could provide a good match with the different diameters of the native arch vessels and the various distances between 2 neighboring arch vessels, and it's placement could become much easier by the arch open technique. Consequently, placement of a modified triple-branched stent graft could be easily used in most patients with acute type A aortic dissection for effective total arch repair.

Balloon valvuloplasty through the right ventricle: another treatment of pulmonary atresia with intact ventricular septum.

BACKGROUND: This was a study to evaluate the safety and feasibility of balloon valvuloplasty of the pulmonary valve through the right ventricle (RV) for the treatment of pulmonary atresia with intact ventricular septum (PA-IVS). METHODS: Ten neonates with PA-IVS, who underwent balloon valvuloplasty of the pulmonary valve through the RV at our institution from January 2008 to May 2010, were enrolled in this study. The oxygen saturation range was 60% to 83% (median 76%). The Z-value range of the tricuspid valve annulus was -2 to 2 (median 0.15), the diameter range of the pulmonary valve annulus was 4.6 to 8.6 mm (median 7.3), and the RV systolic pressure range was 88 to 124 mm Hg (median 106.5). A guidewire was used to perforate the pulmonary valve through the RV, followed by balloon dilation of the valve. The procedure was guided by transesophageal echocardiography. RESULTS: The procedure was carried out successfully in all patients. The procedure time ranged from 64 to 110 minutes (median 82.5). Mechanical ventilation time ranged from 8 to 36 hours (median 11), and hospital stay ranged from 7 to 13 days (median 9). After the procedure, the median oxygen saturation increased to 89.5%, the median RV systolic pressure decreased to 45 mm Hg, and the gradient across the pulmonary valve ranged from 20 to 45 mm Hg (median 27.5). Minor complications included transient supraventricular tachycardia (n = 1), blood loss requiring transfusion (n = 2), moderate pulmonary regurgitation (n = 1), and mild pulmonary regurgitation (n = 3). There were no cases of cardiac perforation, main pulmonary artery aneurysm, or low output syndrome. Follow-up of patients ranged from 8 to 15 months (median 12.3). All patients remained clinically well. CONCLUSIONS: Balloon valvuloplasty of the pulmonary valve through the RV is a safe and feasible alternative to surgical valvotomy or percutaneous balloon dilation. Early results are encouraging.

[Non-invasive ventilation in the treatment of infants with respiratory failure after cardiopulmonary bypass].

OBJECTIVE: To evaluate the effects of non-invasive ventilation in the treatment of infants with respiratory failure after cardiopulmonary bypass (CPB) and extubation. METHOD: Sixty-three infants who had undergone successful surgery with CPB, got respiratory failure after extubation. These infants were randomly divided into two groups: non-invasive (NV) group, treated with non-invasive ventilation and invasive (IV) group, treated with tracheal intubation. The alteration of clinical symptoms, heart rate (HR), respiratory rate (RR), pulse oxygen saturation (SpO2) and blood gas were measured. A comparison was conducted in the incidence of complication and hospital infection, mechanical ventilation time, length of stay in ICU and hospital stay. RESULT: Among the 32 patients in NV group, 1 patient died of heart failure, the remaining 31 patients recovered. Of these 32, 26 patients had relief of respiratory failure, the HR 181 (19.7) bpm, RR 54 (16.7) bpm and PaCO2 55.5(6) mm Hg decreased to 157 (12) bpm, 35 (3.25) bpm, and 42 (10.5) mm Hg, meanwhile SpO2 87% (10.5%), pH 7.29 (0.24), PaO2 55.5(6) mm Hg increased to 96% (3%), 7.37(0.15), 82.5 (11) mm Hg after treatment with non-invasive ventilation (P < 0.01). Six patients underwent tracheal intubation because their condition was not improved. Tracheal hemorrhage or laryngeal edema did not occur in these patients. Among the 31 patients in IV group, 1 patient died of heart failure, the other patients were cured. Of these 30, one patient had tracheal hemorrhage and four patients had laryngeal edema. The incidence of hospital infection in NV group was lower compared with that in IV group. The mechanical ventilation time in NV group 42 (17.2) h was shorter compared with that in IV group 50 (20) h (P < 0.01). There was no significant difference in the length of ICU and hospital stay between the two groups. CONCLUSION: Non-invasive ventilation is a safe and effective method to treat infants with respiratory failure after CPB and extubation.

Closure of perimembranous ventricular septal defects with intraoperative device technique: another safe alternative to surgical repair.

OBJECTIVES: This study aims at assessing the safety and feasibility of intraoperative device closure of the perimembranous ventricular septal defect (VSD). METHODS: Total 89 patients in group I with intraoperative device closure and 58 in group II with surgical repair were enrolled in our hospital to participate in the study from January 2009 to December 2010. In group I, the approach involved a minimal inferior median incision that was performed after full evaluation of the perimembranous VSD by real-time transesophageal echocardiographic guidance, and the insertion of an asymmetric or a symmetric domestically made device was used to occlude the perimembranous VSD. RESULTS: In group I, 83 patients were occluded successfully under this approach. The size of the occluder implanted ranged from 6 to 14 mm. Complete atrioventricular block occurred in one case and Mobitz type II atrioventricular block occurred in one case during the procedure. One patient presented complete atrioventricular block one week after the operation. Two patients converted to surgical repair because of severe intraoperative aortic valve regurgitation. One patient with significant residual shunt transformed to surgical treatment. In our comparative studies, patients in group II experienced significantly longer operative time, ICU stay, and hospital stay (p < 0.001). The cost of group I was less than that of group II (p < 0.001). CONCLUSIONS: Minimally invasive transthoracic device closure of the perimembranous VSD with an asymmetric or a symmetric domestically made device without cardiopulmonary bypass is safe and feasible. It should be considered an acceptable alternative to surgery in selected subgroups. However, it is necessary to evaluate the long-term results.

A modified valve-sparing aortic root replacement technique for acute type A aortic dissection: the patch neointima technique.

We describe a modified valve-sparing aortic root replacement technique for acute type A aortic dissection. After the normal root geometry was restored by removing blood and clots in the proximal false lumen and the valve insufficiency was corrected by simple resuspension of the aortic commissures, three teardrop-shaped patches were sutured inside the sinuses as neointima and then in situ coronary buttons were connected to the small holes created in the corresponding patches. Our initial application showed that this modified valve-sparing aortic root replacement technique is an easy and effective way to restore the geometry of the aortic root and avoid bleeding during surgery for acute type A dissection.

Intraoperative device closure of perimembranous ventricular septal defects in the young children under transthoracic echocardiographic guidance; initial experience.

OBJECTIVES: This study aimed to assess the safety and feasibility of intraoperative device closure of perimembranous ventricular septal defects (VSD) in young children guided by transthoracic echocardiography (TTE). METHODS: We enrolled 18 patients from our hospital to participate in the study from June 2011 to September 2011. A minimal inferior median incision was performed after full evaluation of the perimembranous VSD by real-time TTE, and a domestically made device was inserted to occlude the perimembranous VSD. The proper size of the device was determined by means of transthoracic echocardiographic analysis. RESULTS: Implantation was ultimately successful in 16 patients using TTE guidance. In these cases, the complete closure rate immediately following the operation and on subsequent follow-up was 100%. Symmetric devices were used in 14 patients, and asymmetric devices were used in two patients. Two patient were transformed to surgical treatment, one for significant residual shunting, and the other for unsuccessful wire penetration of the VSD. The follow-up periods were less than nine months, and only one patient had mild aortic regurgitation. There were no instances of residual shunt, noticeable aortic regurgitation, significant arrhythmia, thrombosis, or device failure. CONCLUSIONS: Minimally invasive transthoracic device closure of perimembranous VSDs is safe and feasible, using a domestically made device under transthoracic echocardiographic guidance, without the need for cardiopulmonary bypass. This technique should be considered an acceptable alternative to surgery or device closure guided by transesophageal echocardiography in selected young children. However, a long-term evaluation of outcomes is necessary.