Transcatheter closure of large perimembranous ventricular septal defects from infancy to adulthood with Amplatzer vascular plug II

Introduction

Perimembranous ventricular septal defects (pmVSD) are the most frequent type of VSD. Around 50% will become significant. The surgical approach under cardiopulmonary bypass is the usual treatment for large pmVSD but less invasive ranscatheter closure of pmVSD with rigid asymmetric devices was initially a promising alternative. Unfortunately, despite high success rates, those devices were associated with high incidence of complete heart block, arrhythmias, tricuspid and/or aortic valve dysfunction, and haemolysis. They were abandoned. More recently, limited experience with softer devices has been successful in selected cases. However, closure of large defect in patients with cardiac failure and/or pulmonary hypertension is often not feasible. The aim of this study is to report our experience with large pm VSD defects from childhood to adulthood using the Amplatzer vascular plug II (AVPII) (Abbott, USA), paying particular attention to the impact on conduction tissue.

Method

This retrospective multicenter study included children and adults with hemodynamically significant large (> 8 mm diameter) pmVSD undergoing transcatheter device closure with AVPII between May 2016 and June 2024. A subgroup of patients was paired with control patients undergoing surgical closure for dyssynchrony assessment by echocardiography.

Results

86 patients were included (75% children and 21 < 10 Kg). Success rate was 95% (90% in children < 10Kg). Complications were embolisation (n = 2), new mild aortic and tricuspid regurgitation (n = 2 and 3, respectively). No atrioventricular block occured. Median follow-up was 5.6 years (1 month–7.9 years) in children and 4.7 years (4 months–7.5 years) in adults. 2 children and 2 adults had residual shunt 1-month after the procedure. The left cavities dilation normalised in all cases. No significant rhythm/conduction abnormalities occured. Synchrony assessment was performed in 51 device closure patients and in 51 matched surgical patients. Surgical patients had longer QRS duration and a higher rate of right bundle branch blocks (p = 0.002). The surgical group showed higher prestretch and postsystolic shortening amplitudes and longer time-to-peak postsystolic shortening.

Conclusion

Transcatheter closure of pmVSD using the AVP II through a retrograde approach is safe and effective in children and adults with large pmVSD. This is associated with less electromechanical impairment compared to the surgical approach.