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Surgically-Based
Device
VSD Closure
Olaf Wendler
Department of Cardiothoracic
Surgery
King‘s College Hospital
NO CONFLICT OF INTEREST
TO DECLARE
Background
Conventional Surgical Treatment
Early clinical outcome after surgical repair of acute
ischemic VSD is poor (mortality 30-50%)
- Cardiogenic shock
- Recurrent VSD
- Complications from prolonged ITU
1. Jeppsson A et al. Eur J Cardio-thorac Surg. 2005
2. David TE et al. J Thorac Cardiovasc Surg 1995
Interventional VSD-Closure
Interventional VSD-Closure
• Device closure is established as an option
for VSD closure in paediatric patients
• Case series of ischaemic VSD’s reported
N=18, 5 pts with acute iVSD, early survival 40%
Hypothesis
Hypothesis for Pilot Trial
• Direct surgical closure of an acute iVSD using
an Amplatzer® muscular VSD device to
• Reduce cardiac trauma
– Avoid left ventriculotomy
– Reduce CPB time
– Avoid cardiac arrest
• Achieve full revascularisation
• Reduce incidence of recurrent VSD
• Simplify device deployment
(Ethically approved by the King’s Novel Procedures Committee)
Case Report
A novel surgical approach to close
an acute ventricular septal defect
using an occluder device
Chanaka Rajakaruna (MRCS), Jonathan Hill
(MA, MRCP), Eleanor Jane Holland Turner
(BSc, PhD, MRCS), Alex Sirker (MRCP),
Bushra S Rana (MRCP), Olaf Wendler (MD,
PhD, FRCS)
Departments of Cardiothoracic Surgery and
Cardiology, Kings College Hospital,
London. UK.
Case Report
Patient Data
• 75 y, male
• no past medical History
• Presentation
– Anterior MI
– iVSD 4 d pMI
– Pulmonary oedema
– Cardiogenic shock
Case Report
ECHO
• Anterior VSD
(7-9 mm)
• L to R shunt
(Qp:Qs = 4:1)
• LVEF 45%
• RV preserved
• PAP 50 mmHg
Case Report
Preoperative Treatment
• Insertion of IABP
• Coronary angiography
– LAD 95%, D1 75%
– Cx normal
– RCA occluded, Crux 70%
• Scheduled for surgery when he deteriorated
10 pMI (24. 03. 2006).
Case Report
Operation (I)
• Midline sternotomy & aorto-bicaval cannulation
• On-pump beating heart
– Sequential LIMA
to LAD & D1
– Sequential SVG
to LV branch & PDA
• Epicardial 3-D-ECHO
– VSD of 18-21 mm in the mid septum
Case Report
Operation (II)
• VF induced
• Incision (1.5cm) in the anterior
wall of the RV
• VSD size 20mm, Device 24mm
• Device deployed, direct vision
• RV closed after de-airing
• The patient weaned off CPB with IABP and
Noradrenaline (0.09mcg/kg/hr)
Case Report
Postoperative Course
•
•
•
•
•
Early extubation (6 hours pOP)
IABP for 48 hours
Furosemide infusion (5-10mg/hr)
Adrenaline and Noradrenaline (0.05- 0.1mcg/kg/hr)
Complications
– Chest infection
– Haemothorax secondary to chest drain (day 20)
• Discharged on day 32
Case Report
6 - Months Follow-Up
• Asymptomatic
• NYHA I
• ECHO
- Device well seated
- Residual shunt
through device
(Qp:Qs=2:1)
• PAP 20 mmHg
Summary
Summary
Potential advantages vs.
Conventional surgery
- No incision in the LV
- Reduced CPB time
- No cardiac arrest
Interventional treatment
- Device deployed under direct vision
- Complete revascularization
Conclusion
Conclusion
Limitation
- Residual shunt through the device
Outlook
- Earlier intervention may improve outcome
- Improve surgical technique
- Modification of the device