Experience with percardiac interventions for multiple congenital heart diseases in children

ORIGINAL ARTICLE – CONGENITAL Interactive CardioVascular and Thoracic Surgery 19 (2014) 812–815 doi:10.1093/icvts/ivu232 Advance Access publication 16 July 2014 Experience with percardiac interventions for multiple congenital heart diseases in children Shijun Hu, Yifeng Yang, Yun Zhu, Qin Wu, Rwakaryebe Muhoozi, Shijie Wei, Xiaojie Huang and Tianli Zhao* Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, China * Corresponding author. Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, 139 Renmin Central Road, Changsha, Hunan 410011, China. Tel: +86-731-85295101; fax: +86-731-85295601; e-mail: (T. Zhao). Received 16 January 2014; received in revised form 10 June 2014; accepted 12 June 2014 OBJECTIVES: To report our experience with percardiac interventions for multiple congenital heart diseases in children. METHODS: From April 2010 to December 2013, a total of 64 patients (33 males and 31 females), aged 4.38 ± 2.97 years, with multiple congenital heart diseases underwent attempted percardiac interventional procedures. The cohort included 34 ventricular septal defects (VSDs) with atrial septal defect (ASD), 9 VSDs with patent foramen ovale (PFO), 17 VSDs with patent ductus arteriosus (PDA), 2 VSDs with pulmonary stenosis (PS) and 2 VSDs with ASD and PDA. A mini-incision in the inferior sternum was made, and percardiac device closure and balloon valvuloplasty were performed for VSD, ASD, PDA and PS. RESULTS: Fifty-nine patients (92%) were successfully occluded, and 5 (8%) were converted to open-heart surgery after the failure of occlusion. A total of 111 devices were implanted in the patients (average of 1.88 devices/patient). No severe complications occurred. Incomplete right bundle branch block (IRBBB) occurred in 5 patients (8%) after the operation. Atrioventricular valve regurgitation decreased in 4 patients (6%), but new trivial regurgitation was detected in another patient (2%). A trivial residual shunt without murmur was found in 1 patient (2%), and the residual shunt was closed in the 3-month follow-up. Pericardial effusion occurred in 1 patient (2%). CONCLUSIONS: Treating the patients who have multiple congenital heart diseases with a percardiac intervention is feasible, and the results should be satisfactory. However, more experience and long-term follow-up are mandatory to assess the safety and effectiveness of these procedures as alternatives to conventional therapy. Keywords: Percardiac intervention • Congenital heart diseases • Children INTRODUCTION Multiple congenital cardiac deformities are not rare in patients with congenital heart disease (CHD). Some patients need early invention because of the high risk and mortality associated with an unrestricted left to right shunt. Traditional open-heart surgery with cardiopulmonary bypass (CPB) has been criticized because of associated complications [1], and percutaneous intervention is limited for infants because of small vascular diameters. As a new technology that combines the advantages of percutaneous intervention and traditional surgery, percardiac intervention for CHD has been increasingly used in clinical practice [2–5]. To date, combined CHDs have not been addressed simultaneously by percardiac interventional procedures. Therefore, we present our experience with percardiac interventions for combined CHDs and discuss the efficacy and safety of these simultaneous procedures in children. MATERIALS AND METHODS Clinical data From April 2010 to December 2013, 64 children with combined CHDs were enrolled in this study. The following selection criteria were applied: (i) the patients were clinically recommended for device closure or balloon valvuloplasty; (ii) with no other malformations requiring surgical repair under CPB; (iii) mild atrioventricular valve regurgitation was considered; and (iv) the existence of aortic valve prolapse with moderate to severe aortic valve regurgitation was excluded. All patients were evaluated by transthoracic echocardiography (TTE) before the operation. No other important intracardiac malformations were found. More patient details are given in Table 1. Materials Previous reports have described the device and the delivery system (Shanghai Shape Memory Alloy Co. Ltd, Shanghai, China) used in this cohort [5–7]. The atrial septal defect (ASD) occluder has two discs with different diameters: the right disc is 8–10 mm larger and the left disc is 12–14 mm larger than the connecting waist. Four types of ventricular septal defect (VSD) occluder were designed. The symmetric occluder is concentric, and both discs are 2 mm larger than the waist. The small waist big edge-type occluder is concentric and has two discs with different diameters: the right disc is 4 mm larger and the left disc is 8 mm larger than © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Abstract S. Hu et al. / Interactive CardioVascular and Thoracic Surgery 33 31 4.38 ± 2.97 (0.42–14) 17.21 ± 8.58 (3.5–37) 34 9 17 2 2 Statistical analysis 18 1 All results were expressed as the mean ± standard deviation for continuous variables and as percentages for nominal variables. SPSS for Windows version 20.0 (IBM, USA) was used for the statistical analysis. Gender, age, weight, aortic valve prolapse, mitral regurgitation, tricuspid regurgitation, anatomical type and defect diameter were analysed by binary logistic regression to estimate the closure failure. A P-value of <0.05 was considered statistically significant. 2 1 (2%) 3 (5%) 1 (2%) RESULTS 41 16 7 36 Values are mean ± standard deviation or n (%). All regurgitant severities were mild or less than mild. VSD: ventricular septal defect; ASD: atrial septal defect; PDA: patent ductus arteriosus; PFO: patent foramen ovale; PS: pulmonary valvular stenosis. the waist. The asymmetric occluder is eccentric: the right disc is a circle and 2 mm larger than the waist, and the left disc is an oval with 0 mm towards the aorta to avoid the aortic valve and with the left disc extended 5 mm towards the apex (with a platinum marker guiding device for orientation). The muscular occluder is symmetric with the same disc as the symmetric occluder, but designed with a higher waist measured at 7 mm rather than 3.5–5 mm. The patent ductus arteriosus (PDA) occluder has a 5-mm-tall isosceles trapezoid sagittal section, and its left ventricular flange is 2 mm wider than the connecting waist. The balloon for valvuloplasty and the delivery system are the same as those used in percutaneous intervention. Procedure Two venous access lines were established after general anaesthesia. We performed a further estimate of the suitability of the percardiac intervention and determined whether any undiagnosed but important cardiac abnormalities exist using transoesophageal echocardiography (TEE; Vivid 7 Dimension, GE (...truncated)