Surgically-BasedSurgically-BasedDeviceDevice

VSD ClosureVSD Closure

Olaf WendlerOlaf WendlerDepartment of Cardiothoracic Department of Cardiothoracic

SurgerySurgeryKing‘s College Hospital King‘s College Hospital

NO CONFLICT OF INTEREST TO DECLARE

Conventional Surgical TreatmentConventional Surgical Treatment

BackgroundBackground

Early clinical outcome after surgical repair of acuteEarly clinical outcome after surgical repair of acute

ischemic VSD is poor (mortality 30-50%)ischemic VSD is poor (mortality 30-50%)

- Cardiogenic shock- Cardiogenic shock

- Recurrent VSD- Recurrent VSD

- Complications from prolonged ITU- Complications from prolonged ITU

1. Jeppsson A et al. Eur J Cardio-thorac Surg. 1. Jeppsson A et al. Eur J Cardio-thorac Surg. 2005 2005

2. David TE et al. J Thorac Cardiovasc Surg 19952. David TE et al. J Thorac Cardiovasc Surg 1995

Interventional VSD-ClosureInterventional VSD-Closure

• Device closure is established as an optionDevice closure is established as an option

for VSD closure in paediatric patientsfor VSD closure in paediatric patients

• Case series of ischaemic VSD’s reportedCase series of ischaemic VSD’s reported

Interventional VSD-ClosureInterventional VSD-Closure

N=18, 5 pts with acute iVSD, early survival 40%N=18, 5 pts with acute iVSD, early survival 40%

HypothesisHypothesis

Hypothesis for Pilot TrialHypothesis for Pilot Trial

• Direct surgical closure of an acute iVSD using Direct surgical closure of an acute iVSD using an an Amplatzer® muscular VSD device to VSD device to

• Reduce cardiac traumaReduce cardiac trauma– Avoid left ventriculotomyAvoid left ventriculotomy– Reduce CPB timeReduce CPB time– Avoid cardiac arrestAvoid cardiac arrest

• Achieve full revascularisationAchieve full revascularisation• Reduce incidence of recurrent VSDReduce incidence of recurrent VSD• Simplify device deploymentSimplify device deployment

(Ethically approved by the King’s Novel Procedures Committee)(Ethically approved by the King’s Novel Procedures Committee)

Case ReportCase 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 andCardiology, Kings College Hospital, London. UK.

Case ReportCase Report

• 75 y, male• no past medical History• Presentation

– Anterior MI– iVSD 4 d pMI– Pulmonary oedema– Cardiogenic shock

Patient DataPatient Data

Case ReportCase Report

ECHOECHO

• Anterior VSD Anterior VSD (7-9 mm)(7-9 mm)

• L to R shunt L to R shunt (Qp:Qs = 4:1)(Qp:Qs = 4:1)

• LVEF 45%LVEF 45%• RV preservedRV preserved• PAP 50 mmHgPAP 50 mmHg

Case ReportCase Report

Preoperative TreatmentPreoperative Treatment

• Insertion of IABPInsertion of IABP• Coronary angiographyCoronary angiography

– LAD 95%, D1 75%LAD 95%, D1 75%– Cx normalCx normal– RCA occluded, Crux 70%RCA occluded, Crux 70%

• Scheduled for surgery when he deterioratedScheduled for surgery when he deteriorated10 pMI 10 pMI (24. 03. 2006)(24. 03. 2006)..

Case ReportCase Report

Operation (I)Operation (I)

• Midline sternotomy & aorto-bicaval cannulationMidline sternotomy & aorto-bicaval cannulation

• On-pump beating heart On-pump beating heart – Sequential LIMASequential LIMA

to LAD & D1to LAD & D1– Sequential SVGSequential SVG

to LV branch & PDAto LV branch & PDA

• Epicardial 3-D-ECHO Epicardial 3-D-ECHO – VSD of 18-21 mm in the mid septumVSD of 18-21 mm in the mid septum

Case ReportCase Report

Operation (II)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 ReportCase Report

Postoperative CoursePostoperative Course

• Early extubation (6 hours pOP)Early extubation (6 hours pOP)• IABP for 48 hoursIABP for 48 hours• Furosemide infusion (5-10mg/hr)Furosemide infusion (5-10mg/hr)• Adrenaline and Noradrenaline (0.05- 0.1mcg/kg/hr)Adrenaline and Noradrenaline (0.05- 0.1mcg/kg/hr)• Complications Complications

– Chest infectionChest infection– Haemothorax secondary to chest drain (day 20)Haemothorax secondary to chest drain (day 20)

• Discharged on day 32Discharged on day 32

Case ReportCase Report

6 - Months Follow-Up6 - Months Follow-Up

• Asymptomatic Asymptomatic • NYHA INYHA I• ECHO ECHO

- Device well seated- Device well seated- Residual shunt- Residual shunt through devicethrough device (Qp:Qs=2:1)(Qp:Qs=2:1)

• PAP 20 mmHgPAP 20 mmHg

SummarySummary

SummarySummary

Potential advantages vs.Potential advantages vs.

Conventional surgeryConventional surgery - No incision in the LV- No incision in the LV - Reduced CPB time- Reduced CPB time - No cardiac arrest - No cardiac arrest

Interventional treatmentInterventional treatment - Device deployed under direct vision- Device deployed under direct vision - Complete revascularization- Complete revascularization

ConclusionConclusion

ConclusionConclusion

LimitationLimitation - Residual shunt through the device- Residual shunt through the deviceOutlookOutlook - Earlier intervention may improve outcome- Earlier intervention may improve outcome - Improve surgical technique- Improve surgical technique - Modification of the device- Modification of the device