Zhang Yafei, Wang Kexue, Wang Yanqing, Yang Zaizhen
[Abstract] Objective:To summarize the clinical experience and recent efficacy of transthoracic minimally invasive ventricular septal defect (VSD) occlusion. Methods:After general anesthesia with tracheal intubation, 50 patients with clear diagnosis of simple VSD were entered into the pericardial cavity through a chest wall incision, and the packet was sutured and incised at a suitable location on the right ventricular surface, and the blocker was placed on the VSD site with the aid of a hollow probe or direct delivery method under the monitoring of esophageal ultrasound. Results: 49 cases were successfully blocked, and one case was converted to conventional extracorporeal circulation intraoperatively. Among the successful blockers, the symmetric umbrella was selected in 46 cases and the eccentric umbrella in 3 cases. 3 cases had new micro to mild tricuspid regurgitation, 3 cases had postoperative incomplete right bundle branch block, and 1 case had residual pericardial effusion after removal of the pericardial drain, which was cured by pericardiocentesis. 49 patients had no death, no complete atrioventricular block, no residual shunt, and no new aortic valve closure insufficiency during the perioperative period and recent follow-up. closure insufficiency. Conclusion:Transthoracic minimally invasive VSD occlusion has the advantages of small surgical trauma and high safety, with good recent efficacy, but the long-term efficacy needs further observation. Zhang Yafei, Department of Cardiac and Macrovascular Surgery, Zhengzhou People’s Hospital
[Keywords] Minimally invasive; ventricular septal defect; occlusion
[I.C.C.] R54 [I.D.] A [Article ID] 1007-5062 (2014) 03-000-00
Evaluation of minimally invasive perventricular ventricular septal defect closure for 50 cases ZHANG Yafei,WANG Kexue,WANG Yanqing,YANG Zaizhen Department of Cardiovascular Surgery,People’s hospital of Zhengzhou,Henan Zhengzhou 450003,China
[Abstract] Objective:The paper preliminarily summarizes the clinical experience and short term effects in the chest puncture of minimally invasive treatment with ventricular septal defect(VSD) occlusion. Methods:50 definitely diagnosed patients with VSD are cut from chest into the pericardial cavity under the condition of endotracheal intubations and general anesthesia. Jointing the purse-string and cutting in the suitable position on the surface of the ventriculus dexter. Under the supervision of transesophageal echocardiography, applying the methods of hollow bougie auxiliary and direct transportation to settle the occluder to the VSD part, and releasing the occluder without exception. Results:The procedure was completed successfully in 49 cases and converted to traditional surgical closure with cardiopulmonary bypass in 1 case. Concentric devices were used in 46 cases and encentric devices were used in 3 cases.During the perioperative and short-term follow-up period,there is no death,no complete atrioventr
[Key words] Minimally invasive treatment; Ventricular septal defect; Occlusion
Ventricular septal defect (VSD) is one of the most common congenital heart diseases. Currently, the main treatment methods are surgical repair under extracorporeal circulation and transcatheter interventional occlusion. Traditional surgery involves extracorporeal circulation trauma and potential complications, requires transfusion of blood products, and the surgical scar is aesthetically displeasing. Catheter interventions have radiological damage from prolonged exposure to X-rays, contrast damage, and, furthermore, age and body mass limitations. At present, transthoracic minimally invasive VSD occlusion has been gradually carried out in a few cardiac centers at home and abroad, which can circumvent the effects of extracorporeal circulation and address the radiation damage of interventions as well as the age and body mass limitations of infantile cases, with remarkable clinical results [1-2]. This technique was carried out in our hospital in 2013 and 50 cases have been completed, which are summarized and reported as follows.
Data and methods
1. clinical data From March 2013 to September 2013, we performed 50 cases of transthoracic minimally invasive VSD occlusion using the hollow probe assisted and direct delivery method. All patients underwent rigorous preoperative physical and ancillary examinations, and were clearly identified as simple VSD without other cardiac malformations. 50 patients in this group, 30 males and 20 females; age 0.6-24 years, mean (3.9±5.5) years; body mass 7-80 kg, mean (16.2±14.8) kg; transthoracic and esophageal ultrasound showed effective VSD shunt The size of VSD was 2-8 mm, mean (3.9±1.6) mm; 32 cases with VSD superior margin >2 mm from the aortic valve, 18 cases ≤2 mm, including 5 cases without margin. All patients and guardians had informed consent and signed the informed consent form for surgery.
2. Materials Delivery devices: (1) Hollow probe method: including hollow probe, guiding wire, dilating sheath and delivery sheath, loading sheath, and push rod. (2) direct conveying method: including only the conveying sheath tube and pushing rod. The tip of the hollow probe bar is expanded and rounded. There are various types of delivery sheaths and loading sheaths according to the size of VSD. There is a side branch exhaust pipe at the end of the delivery sheath.
The blocking device adopts the domestic VSD blocking device produced by First Health Technology (Shenzhen) Co. Concentric sheaths are short-sided sheath (side length 2mm), broad-sided sheath (side length 4mm on the left ventricular surface) and myocardial sheath (waist height 5mm); eccentric sheaths have a side length of 0.5mm on the left ventricular surface and a lower side length of 4mm; all have various models for selection.
3. Procedure General anesthesia, supine position, placement of esophageal ultrasound, measurement of VSD position, VSD left ventricular surface and right ventricular surface size, distance from the aortic valve and tricuspid valve. The appropriate type and type of blocker was selected. A small median incision in the lower sternum, 1.5-62.5 px in length, splits the lower 1/3 of the sternum, partially dissects and drapes the pericardium to reveal the free wall of the right ventricle. For high intracrural VSD, the left parasternal 2nd or 3rd intercostal space is chosen to enter the anterior mediastinum, push the thymus, and partially dissect and suspend the pericardium. The anterior wall of the right ventricle is pressed with “peanut butter”, and a site close to the VSD and at a suitable angle is selected for the pericardial suture under esophageal ultrasound monitoring. 5-0 Prolene suture is placed in a double “U” shape. The ruffle. Hollow probe method: The sharp knife punctures the central part of the right ventricular wall of the pericardium and places a hollow probe, tightens the pericardium, and under the guidance of esophageal ultrasound, the hollow probe enters the left ventricle through the VSD, at which time bright red blood is ejected from the end of the hollow probe. The guiding wire is inserted along the probe hole into the left ventricle and the hollow probe is replaced. Select the appropriate type of dilating sheath and delivery sheath, feed them into the left ventricle along the guidewire, note the depth in the left ventricle, fix the delivery sheath, and remove the guidewire and dilating sheath. The loading sheath with the blocker is docked to the delivery sheath, the blocker is pushed into the delivery sheath, the left disc surface of the blocker is pushed and released under esophageal ultrasound monitoring, and after retracting the entire sheath so that the left disc surface is tight against the left ventricular surface of the septum, the waist and right disc surface of the blocker are released so that the right disc surface is tight against the right ventricular surface of the septum. If the esophageal ultrasound confirms that the blocker is well positioned, there is no displacement by gentle push-pull test, no residual shunt, and no atrioventricular valve activity obstruction, the blocker can be released. Direct delivery method: The blocker is pushed directly into the delivery sheath tube to expose the tip of the blocker, and the delivery sheath tube carrying the blocker is inserted directly through the intra-pericardial puncture point of the right ventricular wall, and the release of the blocker is completed by entering the left ventricle through the VSD under the guidance of esophageal ultrasound. The push rod and delivery sheath were removed, and the right ventricular load was ligated. Half amount of fisetin is neutralized and complete hemostasis is achieved. Sterile saline is used to flush the pericardial cavity. A single-chamber central venous cannula is placed percutaneously through the pericardium as a drainage tube. The chest was closed layer by layer. After normal postoperative decannulation, heparin anticoagulation (2 mg.kg-1.d-1) was applied after 6 h drainage reduction, and anticoagulation was replaced with oral aspirin (3 mg.kg-1.d-1) on the second postoperative day, which was applied until 3-6 months after surgery. Ultrasound, chest X-ray and electrocardiogram were reviewed before discharge, 1 month, 3 months and 6 months after surgery, respectively. Thereafter, every 6 months, physical examination, review of ultrasound, chest X-ray and ECG were performed.
4. Statistical methods All data were processed using SPSS10.0, and the measurement data were expressed as mean ± standard deviation, and the difference was considered statistically significant at P<0.05. < span="">
Results
Sealing was successful in 49 patients (Table 1), and in 1 case, the ventricular defect was too small for the probe to pass and was repaired under extracorporeal circulation. The blocker was placed in the aneurysm of the VSD membrane in 8 cases; the upper edge of the VSD was not marginal to the aortic valve in 5 patients, of which 3 cases applied an eccentric umbrella and 2 cases applied a short-sided concentric umbrella. The intracardiac operation time ranged from 5 to 90 min, with a mean of (21.5±13.7) min. 3 patients had intraoperative replacement of the blocker. The tracheal intubation was removed within 3 h after surgery, and the whole group was discharged without blood transfusion about 5 d after surgery. In one case, a medium amount of pericardial effusion remained after removal of the pericardial drainage tube after surgery, which was cured by pericardiocentesis. 3 cases had new micro to mild tricuspid regurgitation, and 3 cases had incomplete right bundle branch conduction block after surgery, which did not increase or disappear after follow-up. At postoperative follow-up from 1 to 9 months, no death, complete atrioventricular block, residual shunt occurrence, new aortic valve closure insufficiency, blocker dislodgement, hemolysis, or embolism occurred in 49 patients.
Table 1 Delivery method and use of blocker type
Type of VSD
Delivery method
Type of blocker
Hollow probe method
Direct conveying method
Short-sided umbrella
Wide edge umbrella
Muscular umbrella
Eccentric umbrella
Membrane perimeter (n=45)
32
13
38
3
1
3
Intracrater (n=3)
1
2
3
Muscular (n=1)
1
1
DISCUSSION
In recent years, surgical transthoracic minimally invasive VSD occlusion has been rapidly applied in China, and the results of a multicenter study [3] showed that it has the following advantages: 1 small incision, routinely 37.5px-62.5px, aesthetic appearance and imperceptible after healing; 2 avoiding the trauma of conventional surgery and the potential complications of extracorporeal circulation; 3 avoiding the radiation of X-rays and the damage of contrast agents in medical interventions; avoiding the If the VSD is found to be unsuitable for occlusion or fails to be occluded, the incision can be extended upward and the operation can be performed under extracorporeal circulation, which ensures the safety of the child; (7) the whole operation is performed under esophageal Ultrasound monitoring and electrocardiographic monitoring can maximize the avoidance of major complications such as intraoperative residual shunt, arrhythmia (conduction block), and valvular regurgitation.
Currently, most of the operative methods for blocker placement use a free wall puncture of the right ventricle and an esophageal ultrasound-guided wire to establish a track through the VSD into the left ventricle. By reviewing the literature [4] and observing and learning, we applied the hollow probe method and the direct delivery method to complete the blocker placement, which are simpler and easier to learn than the guidewire method of blocking and safer in the treatment process, and their advantages are more prominent in the blocking of small VSDs. Preliminary results also confirm the high success rate of occlusion. According to our strict preoperative screening, except for one case in which the ventricular defect was too small to be transferred to surgery through the probe, all the remaining 49 cases in this group were successfully performed transthoracic occlusion, and the average intracardiac operation time was relatively short, with the fastest one completed in a few minutes.
The selection of surgical indications varies from unit to unit [4-5]. Due to the initial development and introduction of this technology, we are relatively strict about the indications for surgery, which are as follows: age >6 months; membrane VSD opening, myocardial and cristae VSD ≥2 mm; VSD membrane tumor left ventricular surface ≤12 mm and outlet <10 mm; myocardial and cristae type vsd ≤5 mm; pulmonary artery systolic pressure <50 mmhg< span="">(1 mmHg=0.133kPa). The main contraindications include: multiple myocardial VSDs as well as substernal VSDs combined with aortic valve prolapse; those with significant aortic valve prolapse; large nonrestrictive VSDs with poorly defined borders or combined with more than moderate pulmonary hypertension; and other cardiac malformations requiring direct visual correction. For the indications of minimally invasive transthoracic occlusion of sub-stem VSD, the current domestic expert consensus is: sub-stem VSD without combined aortic valve prolapse and VSD <6 mm in those less than 1 year old. special types of occluders compatible with vsd are required for the selection of the type of occluder, and general eccentric occluders are not suitable< span="">[6]. Considering the technical factors and the possible pulmonary regurgitation caused by the placement of the blocker, we did not perform it. We believe that the indications for this type of patients should still be strictly controlled according to each unit’s own technical level and comprehensive conditions. We have not performed the procedure for patients who can undergo simultaneous interventional occlusion, such as VSD combined with patent ductus arteriosus and VSD combined with pulmonary valve stenosis, because of technical considerations and medical costs. In terms of the grasp of surgical indications, the author believes that another is the strength of the heart murmur, the heart murmur below grade 2 on auscultation, the ventricular defect is generally small, even if the probe strip method is used, it is very difficult to pass the ventricular defect, and should be strictly screened. One of our cases of intermediate surgical procedures falls into this category.
The choice of the type and type of blocker is based on the location and size of the VSD, the distance between the upper edge of the VSD and the aortic valve, and the opening and size of the membranous aneurysm.1 If the upper edge of the VSD is ≥2 mm from the aortic valve, the corresponding type of short-sided umbrella is usually selected according to the diameter of the VSD +2-3 mm; if only the membranous aneurysm of the VSD is blocked, the corresponding type of short-sided umbrella is selected according to the diameter of the opening of the membranous aneurysm +2-4 mm. If the VSD is far from the aortic valve, the left ventricular surface of the membranous aneurysm is large and there are multiple shunts on the right ventricular surface, choose a wide-sided umbrella with a VSD diameter of +5-7mm; if the upper edge of the VSD is <2mm from the aortic valve, choose an eccentric umbrella with a vsd diameter of +2-3mm; in this group of patients, there are 5 cases with a vsd upper edge <2mm from the aortic valve, 3 of them apply an eccentric umbrella and the other 2 cases apply an eccentric umbrella. The short-sided concentric umbrella applied in the other 2 cases was not found to affect the aortic valve causing regurgitation, and none of them affected the right or left ventricular outflow tract, but it is still recommended that an eccentric umbrella is preferable;< span="">3 those with high myocardial VSD and VSD membrane aneurysms should choose a high waist myocardial umbrella.
During the whole procedure, there is full monitoring by esophageal ultrasound and cardiac monitoring, thus in case of residual shunt, valve closure insufficiency and severe conduction block, the blocker can be timely detected and recovered for replacement or changed to extracorporeal circulation surgery with high safety. In three cases, the intraoperative blocker was too small and residual shunt appeared at the edge of the blocker, so the blocker was replaced with a larger one and the residual shunt disappeared. The patients in this group had shorter postoperative ventilator-assisted time, ICU stay and hospital stay, and no blood transfusion, reflecting the advantages of minimally invasive and less painful transthoracic occlusion.
There were 3 cases of new postoperative micro to mild tricuspid regurgitation, 2 without regurgitation and 1 without increase at 6-month follow-up. 3 cases of incomplete right bundle branch conduction block occurred postoperatively, 2 disappeared and 1 existed during follow-up. In one case, after removal of the pericardial drainage tube postoperatively, a repeat ultrasound showed a medium amount of pericardial effusion at the time of discharge, which was then cured by pericardiocentesis. The main consideration was that the pericardial drainage tube was blocked, and the ultrasound was not reviewed at the time of removal. This also suggests that we should stop the bleeding thoroughly during the operation, and remove the drainage tube after confirming that the drainage is clear and there is no obvious fluid in the pericardial cavity after the operation. At postoperative follow-up from 1 to 9 months, there were no deaths, complete AV block, residual shunts, new aortic valve insufficiency, blocker dislodgement, hemolysis, or embolism in 49 patients. The initial results were satisfactory, but further follow-up is needed for medium- and long-term outcomes to closely observe the effects of the blocker in vivo on aortic valve structure, tricuspid valve closure, cardiac function, and electrocardiographic activity.
In the last decade, the treatment paradigm for congenital heart disease has evolved from a single surgical procedure to a combination of surgical, interventional, and inlay treatments [7]. Transthoracic minimally invasive VSD occlusion combines the advantages of medical interventions as well as surgical procedures, and is characterized by low trauma, high safety, and still satisfactory results in the near term. For the medium- and long-term therapeutic effects, multi-center and long-term follow-up of a large number of cases are still needed.
References
[1] Li F,Chen M,Qiu ZK,et al. A new minimally invasive technique to occlude ventricular septal defect using an occluder device.Ann Thorac Surg,2008,85:1067-1071.
[2] Yin Q S, Wu Q. Progress of transthoracic minimally invasive non-extracorporeal circulation for occlusion of ventricular septal defects. Chinese Journal of Thoracic and Cardiovascular Surgery.2011,27:257-258.
[3] HING Qiansheng,PAN Silin,WU Qin,et al. Transthoracic minimally invasive non-extracorporeal occlusion of ventricular septal defects: multicenter experience and recent midterm follow-up results. Chinese Journal of Thoracic and Cardiovascular Surgery.2011,27:259-258.
[4] Li H X, Zhang H, Guo W B, et al. Probing-assisted minimally invasive ventricular septal defect closure. Chinese Journal of Thoracic and Cardiovascular Surgery.2011,27:271-272.
[5] Zhang YZ, Li HX, Huang, et al. Clinical study of transthoracic minimally invasive ventricular septal defect occlusion. Hebei Med. 2012,34:2746-2747.
[6] Chinese Physicians Association, Cardiovascular Surgery Branch. Chinese expert consensus on transthoracic minimally invasive ventricular septal defect occlusion. Chinese Journal of Thoracic and Cardiovascular Surgery. 2011,27:516-518.
[7] Xiao YY, Jin ME, Han L, et al. History and new advances of interventional treatment for congenital heart disease. Journal of Cardiopulmonary Vascular Disease. 2012,31:755-758.
Author Affiliation：450003 Henan Zhengzhou People’s Hospital, Department of Cardiac and Macrovascular Surgery (Zhang Yafei, Wang Kexue, Yang Zaizhen) , Department of Ultrasound (Wang Yanqing)
Correspondence should be addressed to Zai-Zhen Yang, MD, Chief Physician, Research interests: Basic and Clinical Cardiovascular Surgery. e-mail: [email protected]