Transcatheter trans-septal antegrade closure of muscular ventricular septal defects in young children.

BACKGROUND: Surgical or transcatheter closure of muscular ventricular septal defects (mVSDs) in young children may be technically challenging and associated with significant complications. OBJECTIVE: To assess the feasibility of trans-septal antegrade closure of mVSD in a selected subset of young children. METHODS: This is a prospective study from a single centre from July 2011 to March 2013. Nine infants and children with single or multiple mVSDs were included in the study. The median age and weight were 6 months (range 4-18 months) and 4.5 kg (range 3.8-6.2 kg), respectively. Trans-femoral trans-septal antegrade technique was used in eight children. One child was excluded from the study because of abnormally tortuous anatomy of both the femoral veins and subsequently underwent VSD device closure by the trans-jugular approach. The follow-up evaluation included chest X-ray, ECG, and echocardiogram at 1 month, 3 months, 6 months, and 1 year. RESULTS: The defects were closed successfully in all eight patients using Amplatzer mVSD device in 5 and Amplatzer Duct Occluder II in 3. Moderate mitral regurgitation due to entrapment of the anterior mitral leaflet occurred in one patient with a posteriorly located mVSD, necessitating removal of the device, and surgical closure of the mVSD. The small additional residual mVSD in one other patient closed spontaneously during the follow-up. CONCLUSIONS: Transcatheter trans-septal antegrade closure of mVSD in young children is technically feasible and merits further consideration. Symptomatic relief in multiple mVSD can be achieved after closing larger defects.

Retrograde transcatheter closure of ventricular septal defects in children using the Amplatzer Duct Occluder II.

OBJECTIVES: To describe the technique and results of transcatheter closure of ventricular septal defects (VSDs) by a modified retrograde transarterial approach using the new Amplatzer Duct Occluder II (ADO II). BACKGROUND: Transcatheter device closure of ventricular septal defects (VSDs) by antegrade method is well established, but a challenging procedure. We describe a retrograde technique that obviates the need for arteriovenous looping. MATERIAL AND METHODS: This is a prospective study from a single center. Between April 2009 and February 2010 13 children were identified for closure of various types of perimembranous and muscular VSDs using the ADO II device. All had met the criteria for surgical closure. Following left ventricular angiogram two were excluded as technically nonfeasible. The median age was 48 months (range 15-78). The median weight was 14 kg (range 7.5-20). The device was successfully deployed in the 11 selected children by the method described. The follow-up evaluation included chest roentgenogram, ECG, and echocardiogram on day 1, at 6 weeks, at 3, 6, and 12 months. RESULTS: The immediate and follow up complete closure rates were 73 and 82%, respectively. The median fluoroscopic time was 14 min (range 8.2-45). There were no procedure related complications. All patients were doing well at median follow up of 10 months; none showing any conduction abnormality. CONCLUSION: Transcatheter retrograde device closure of selected cases of Ventricular Septal Defects using the Amplatzer Duct Occluder II is simple and appears safe in the short term and can be completed within a short fluoroscopic time.

Rescrewing the embolized duct occluder using the delivery cable.

We report the successful re-screwing of the embolized duct occluder (DO) in three children for retrieval and to attempt redeployment. The DO was embolized into descending aorta immediately after the deployment in one child and within 24 h after the procedure in two further patients. The DO was re-screwed back by the DO delivery cable, using "sheath in sheath" in all three cases; however, successful retrieval could be done only in two. Repositioning in the patent ductus arteriosus (PDA) was done using the same device in those two children and surgical removal was needed in third child with perimembranous ventricular septal defect.

Transcatheter closure of large right pulmonary artery-to-left atrial fistula.

We report the successful transcatheter closure of right pulmonary artery fistula to left atrium in a six-year-old boy, who had presented with cyanosis and shortness of breath. The two-dimensional echocardiogram with bubble contrast study demonstrated the communication between right pulmonary artery and left atrium. Computerized tomography confirmed the diagnosis and delineated the anatomy. The fistula was closed successfully by a transcatheter trans-septal approach using an 18/20 duct occluder.

Unexpected difficulty during transcatheter device closure of atrial septal defect associated with right aortic arch.

Right aortic arch (RAA) associated with isolated atrial septal defect (ASD) is very rare. We report successful closure of ASD associated with RAA using a 26-mm atrial septal occluder in a 30-year-old male patient. The impingement of right descending aorta in RAA caused malposition of the device in the left atrium. Deployment of the device through the right upper pulmonary vein successfully closed the defect. Follow-up evaluation by computerized tomography scan and echocardiogram showed no pulmonary venous obstruction.

Coronary artery bypass grafting with or without cardiopulmonary bypass in patients with preoperative non-dialysis dependent renal insufficiency: a randomized study.

OBJECTIVE: Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing coronary artery revascularization with cardiopulmonary bypass. Off-pump coronary artery bypass grafting has been shown to be less deleterious than on-pump bypass in patients with normal renal function, but the effect of this technique in patients with non-dialysis dependent renal insufficiency in a randomized study is unknown. METHODS: From August 2004 through October 2005, 116 consecutive patients with preoperative non-dialysis-dependent renal insufficiency (glomerular filtration rate measured using the Modification of Diet in Renal Disease equation [MDRD GFR] < or = 60 mL x min(-1) x 1.73 m(-2)) undergoing primary coronary artery bypass grafting were randomized to on-pump (n = 60) and off-pump (n = 56) groups. MDRD GFR and serum creatinine levels were measured preoperatively and postoperatively at days 1 and 5. The changes in renal function and clinical outcomes were compared between the two groups. RESULTS: Preoperative characteristics were comparable between the two groups. The repeated-measures analysis of variance was performed on the data that showed worsening of renal function in the on-pump group compared with the off-pump group (serum creatinine, P < .000; glomerular filtration rate, P < .000). Further analysis of subgroups of patients with diabetes alone, hypertension alone, and combined hypertension and diabetes also showed significant deterioration renal function in the on-pump group compared with the off-pump group. In covariate analysis, diabetes has emerged as a significant covariate by serum creatinine criteria while compromised left ventricular function has emerged as a significant covariate by glomerular filtration rate criteria. These analyses showed that the use of cardiopulmonary bypass is significantly associated with adverse renal outcome (P < .000). Three patents required hemodialysis in the on-pump group and none in the off-pump group. The mean number of grafts per patient was 3.85 +/- 0.86 and 3.11 +/- 0.89 in the on-pump and off-pump groups, respectively (P < .001), but the indices of completeness of revascularization, 1.00 +/- 0.08 for off-pump coronary bypass and 1.01 +/- 0.08 for on-pump coronary bypass, were similar (P = .60). CONCLUSIONS: This study suggests that on-pump as compared with off-pump coronary artery bypass grafting is more deleterious to renal function in diabetic patients with non-dialysis dependent renal insufficiency. MDRD GFR is a more sensitive investigation than serum creatinine levels to assess renal insufficiency in patients undergoing coronary bypass.