Update of Transcatheter Closure of Ventricular Septal Defect in China

Yong-wen Qin

Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai

1 、 The number and quality of VSD intervention improved during past ten years

The first pmVSD patients treated with symmetric occluder (2001.12 ， 21)

The first post-MI VSD patient treated with symmetric occluder (2001.10)

The first cases of VSD intervention in our center

Development of CHD intervention from 1990s-2011 in China

year

Patient number

*

VSD intervention in last 3 years in China （ 394 hospitals ）

2009 2010 2011

total 16045 18671 22967

ASD 5527 6793 8089

PDA 4705 5466 4075

VSD 3521 4252 5474PBPV 603 680 905

Success rate 97.24% 97.67% 98.11%

Complication 0.2% 0.17% 0.12%

Mortality 0.03% 0.05% 0.02%

2 、 Three kind of VSD devices in

vented and clinical use in China

Modified VSD device in China

symmetric occluder thin waist occluder asymmetric occluder

Schematic diagram of ventricular septal defect occluder

The classification of VSD by ventriculography

A tubular B window-like C aneurysmal D infundibular

Individualization choice of the occluder according to anatomy of VSD

Infundibular VSD

symmetric occluder

How to choose the occluder according to VSD

Intracristal VSD

asymmetric occluder

Intracristal VSD

Intracristal VSD

Symmetric device ---Aortic valve regurgitation

asymmetric device ---no aortic valve regurgitation

Intracristal VSD

Intracristal VSD

Intracristal VSD

Aortic valve regurgitation--- device inclined to one side

The direction of left disk marker should be apex

Intracristal VSD

When the marker turn to apex, aortic valve regurgitation became trace

Intracristal VSD

No aortic valve regurgitation-- long rim direction pointed to cardiac apex

PV

VSD

Echo: subpulmonary VSD---near PV

VSD complicared with aortic valve prolapse

VSD 5mm ----- 0 rim device (10mm)

Postoperation, no aortic regurgitationHowever, occluder maybe oversized

VSD 7mm, near aortic valve

Echo: subpulmonary VSD---near PV

Device 9mm (L), change to Device 11mm (R)

no aortic valve regurgitation

Multi-hole VSD---device choice

multi-hole VSD

thin waist occluder

One device close three holes

VSD2

VSD1

deviceFor VSD2

VSD1

VSD with two holes

Two device for two holes

Large VSD -1

Large VSD -2

14mm A6B2 device

Large VSD -3

No aoric valve regurgitation ,no TVR

PDA device for large VSD

PDA device for large VSD

20mm PDA device

PDA device for large VSD

Post-myocardial infarction VSD

Postoperative residual perimembranous VSD

Transcatheter closure of postoperative residual perimembranous VSD

PS and large VSD

VSD 17mm, device 24mm

3 、 Conduction Block complicated with VSD

Intervention: experience in china

anthor sample AVB% cAVB% PPM onset recovery

Song et al 328 27(8.2%) 8 0 12h-6 14-20d

Xie et al 644 16(2.5%) 6 2 3-6d 8-10dWang et al 364 20(5.5%) 4 0 3-14d NA

Zhang et al 232 17(7.3%) 12 0 4-6d 4-27d

Wu et al 112 22(19.6%) 0 0 5d 5d

Zhu et al 358 23(6.4%) 5 0 1-8d 6-10d

Liu et al 210 41(19.5) 6 1 7d 21d

Yu et al 112 37(33%) 8 0 3-9d 3-7d

Qin et al 203 11(5.4%) 1 0 2-5d 5-10d

Past Literature Review in China

Clinial trial data of Amplatzer VSD device

Catheter Cardiovasc Interv. 2006, 68(4):620-8. (n=100)

J Am Coll Cardiol. 2006, 47(2): 319-25. (n=35)

Eur Heart J. 2007, 28: 2361. (n=430)

N: 565

Success rate 91-95 ％3rd AVB 2-8 ％PPM 12 (3.8 ％ )

death 1

The data on VSD occluder in China from 21 centers (N=9311, 2007)

Success rate 96.45% Death 0.05% (5) Transient cAVB 0.63% (59) PPM 0.09% (8)

2011 registry data in China

5474 cases with vsd in 394 hospital in china

PPM 1case

The data from Changhai hospital (2001-2012)

2001-2002, 196 cases underwent percutaneous procedure (using sy

mmetry device), no cAVB

2003-2006, among 300 cases (Symmetry , Eccentric 、 thin waist de

vices), 11 cases complicated transient 3rd degree AVB, permanent

pacemaker occur in 1 case

2007-2012, sequence 550 cases with Symmetry , Eccentric,thin wai

st devices, cAVB occur 1 patient

The possible reason of increase AVB from 2003 to 2006 ?

Patients: patients non-selected, consecutive patients admitted

Doctors: personnel stability, and operation technology maturity

Indication: increased intracristal multi-holes and aneurysm type VSD

Devices: Application of asymmetric occluder

Device waist length and AVB

2001--2003---more than 3.5 mm---no case with AVB

2003--2006---less than 2.5mm---12/300 with AVB

2007--2012---more than 3.5mm---no case with AVB

Chinese device shape at immediate compared with amplatzer devices

amplatzer devices Shape changeAVB

device shape at immediate

3rd AVB

My opinion is that device is key factor for conduction block.

Device tension---flex

Contact area with the septal

Size --- waist diameter

Length of waist

The risk factor of AVB

Choose the proper device size Avoid oversized device

AVB seems to be fewer in symmetric occluder.

“Nice” occluder Individualized choice of occluder for pts Very experienced hands

Major success experience on prevention of AVB

Other Risk factors for the Occurrence of AVB

Type of VSD:

perimembranous VSD

inlet VSD (behind the septal leaflet of

tricuspid valve)

The VSD intervention is safe, effective

and an alternative method to surgery

or first choice in China

Wire-Maintaining Technique

Using this novel technique, the reconstruction of ‘‘arteriovenous wire loop’’ could be avoided in patients requiring device replacement.

QIN, et al. CCI 75:66–71 (2010)

4 、 Useful technique in intervention of VSD

Large VSD (22mm) Wire-Maintaining Technique

How to choose the patient for VSD closure----TTE three views

the apical 5-chamber view LV long axis l view Aortic short axis view

Compared to TEE, TTE is enough!

Thank youThank you