Abstract: Objective To retrospectively study the morphological characteristics of transverse ventricular septal meningioma and the operation rules of interventional treatment. PATIENTS AND METHODS Twelve patients (6.8±2.4 years old) with ruptured transverse septal membranous aneurysm had a mean diameter of 5.55±2.47 mm (3.8-8.4) at the base of the membranous aneurysm and a mean transverse diameter of 6.82±3.27 mm (4.92-8.41) of the membranous aneurysm, as measured by echocardiography, and 9 patients had a single rupture, and the mean distance of the membranous aneurysm margin from the aortic valve was The average distance between the edge of the membranous aneurysm and the aortic valve was 1.52±0.84 mm (0.9~2.56). The mean pulmonary artery systolic pressure in this group of patients was 24.47±2.71 mmHg (22-28), and the mean Qp/Qs was 1.78±0.32 (1.34-2.05). RESULTS: Head-axis left ventriculography showed a transverse position of the membranous aneurysm, with a mean diameter of 6.22±1.44 mm (5.98-7.33) at the base of the membranous aneurysm and a mean transverse diameter of 8.22±0.78 mm (6.37-10.71) at the base of the membranous aneurysm, and a single rupture in 8 patients, with a mean diameter of 3.48±0.91 mm (2.55-4.97) at the rupture. The mean distance of the basal edge from the aortic valve was 0.94±0.73 mm (0.6~2.8). The left ventriculography revealed that the aneurysm in this group was transverse, with a smaller base and the transverse diameter of the aneurysm was larger than the diameter of the base, and the aneurysm was dumbbell-shaped transverse in three patients. 10 cases had ruptures located below or to the right of the aneurysm, and most of the shunted blood was directed to the lower right side, and two cases had ruptures located to the right of the aneurysm. All patients in this group underwent interventional occlusion with a 100% technical success rate. In 8 cases, the concentric septal blocker was used, and in 4 cases, the eccentric septal blocker was used. 9 patients had direct blocking of the base of the tumor, and in 4 cases, the eccentric septal blocker was used; in the other 3 cases, the rupture port was blocked. All the postoperative heart murmurs disappeared, and immediate left ventriculography revealed a small amount of residual in 2 cases, with a residual shunt rate of 16.7%, and no aortic regurgitation on aortogram. The residual shunt rate (1/12) was 8.3% on echocardiography 1 month after the procedure, and there were no residual shunts on review 6 months after the procedure. Conclusion According to the morphological characteristics of transverse ventricular septal membrane tumor during the interventional treatment, the key interventional operation steps such as passing the guidewire through the ventricular septal defect orifice, avoiding the guidewire to pass through the tricuspid tendon cord and releasing the blocker were adopted accordingly, and the interventional occlusion could be successfully performed. Li Fuhai, Department of Pediatrics, Qilu Hospital, Shandong University, China Keywords Transverse ventricular septal tumor; diagnosis; intervention Transcatheter closure of horizontal aneurysm-like perimembranous ventricular septal defects The morphology of ruptured ventricular septal tumors is diverse, generally round or semicircular, and the rupture opening is mostly above or to the right of the tumor [1,2]. Based on the presentation in left ventriculography, a transverse membranous tumor is defined as a ruptured septal membranous tumor with localized protrusion of the septum into the right ventricle, a relatively small basal diameter, and a membranous tumor with a transverse diameter larger than the basal diameter and an intact tumor wall. Because of its unique morphology, its interventional procedures also have their special characteristics. In this paper, we summarize the interventional treatment of 12 cases of ruptured transverse septal meningioma with complete data in the past 5 years, and try to analyze their diagnosis and interventional operation rules. General data There were 12 patients with ruptured transverse septal membrane tumors in this group, with a mean age of 6.8±2.4 (3-11) years, 8 males and 4 females. The mean diameter of the base of the membranous aneurysm was 5.55±2.47 mm (3.8-8.4) and the mean transverse diameter of the membranous aneurysm was 6.82±3.27 mm (4.92-8.41) as measured by echocardiography. The mean pulmonary artery systolic pressure in this group of patients was 24.47±2.71 mmHg (22-28), and the mean Qp/Qs was 1.78±0.32 (1.34-2.05). The cephalometric left ventriculogram showed a transverse position of the membranous aneurysm with a mean diameter of 6.22±1.44 mm (5.98-7.33) at the base of the membranous aneurysm and a mean transverse diameter of 8.22±0.78 mm (6.37-10.71) at the base of the membranous aneurysm, and a single rupture in eight patients with a mean diameter of 3.48±0.91 mm (2.55-4.97) at the base of the membranous aneurysm. The average distance of the edge from the aortic valve was 0.94±0.73 mm (0.6-2.8). The left ventriculography revealed that the aneurysms in this group were transverse, with a smaller base, and the transverse diameter of the aneurysm was larger than the diameter of the base. 3 patients had a dumbbell-shaped transverse position of the aneurysm. 10 cases had ruptures located below or to the right of the aneurysm, and most of the shunted blood was directed to the lower right side, and 2 cases had ruptures located to the right of the aneurysm. In this group, no aortic regurgitation was detected by echocardiography and ascending aortogram.
As a result, all patients in this group underwent interventional occlusion with a 100% technical success rate. In 8 cases, the concentric septal blocker was used, and in 4 cases, the eccentric septal blocker was used. 9 patients had direct blocking of the base of the aneurysm, and in 4 cases, the eccentric septal blocker was used; the other 3 patients had blocking of the rupture. All the postoperative heart murmurs disappeared, and immediate left ventriculography revealed a small amount of residual in 2 cases, with a residual shunt rate of 16.7%, and no aortic regurgitation on aortogram. The residual shunt rate (1/12) was 8.3% on echocardiography 1 month after the operation, and there was no residual shunt on review 6 months after the operation.
Discussion Most of the ruptured septal membranous tumors demonstrated on left ventriculography were pseudo-ruptured membranous tumors. The actual anatomical manifestation is a tubular membranous structure formed after adhesions between part of the tricuspid septum and the tendons near the defect orifice under the impact of blood flow. Due to the location of the defect and the direction of blood flow, the morphology of the resulting tubular structure varies [3,4], and transverse membranous tumor is only one of the specific types. The rupture of transverse membranous aneurysms is mostly located below the membranous aneurysm, and the main blood shunt direction is toward the apical part of the heart, and the angle between the shunt direction and the longitudinal axis of the aorta is greater than 90°. In a few cases, the rupture is gourd-shaped or there may be multiple ruptures. Transverse septal tumors are not only different from other types of membranous tumors in terms of morphology, but more importantly, their morphological structure directly affects the implementation of interventional treatment. : 1. Passing the guidewire through the septal defect opening: Most of the transverse septal membranous tumors have the rupture opening toward the apical part of the right ventricle. When a conventional catheter (e.g., right coronary catheter) is applied for exploration, the running direction of the guidewire after exiting the catheter faces upward or runs toward the right side, which may cause the catheter to pop out of the membranous tumor with the entry of the guidewire due to the contact of the guidewire with the wall of the membranous tumor. Therefore, we cut and shaped the head end of the pigtail contrast catheter so that the curvature of the head is greater than 90° and the head of the catheter points downward to the right, so that the guidewire can easily enter the right ventricle through the rupture after exiting the catheter. 2. Avoid passing through the tricuspid tendon: In this group of patients, we found that the guidewire passed through the tricuspid tendon after circling the orbital guidewire, which may be due to the fact that the orbital guidewire reaches the apical part of the right ventricle first after exiting the rupture, and then turns upward to reach the pulmonary artery. This may be due to the fact that the orbital guidewire exits the rupture and reaches the right ventricular apex and then turns upward to the pulmonary artery, where it can easily cross the tricuspid tendon. If such a situation occurs, the catheter head can be crossed over the rupture into the right ventricle, and the guidewire can be incorporated into the catheter under posterior anterior fluoroscopy, and the direction of the catheter head can be reoriented so that the guidewire enters the superior vena cava through the tricuspid valve, and the right coronary catheter can be replaced or the direction of the catheter can be adjusted to guide the guidewire into the superior vena cava if necessary. 3. Release of the blocker: The diameter of the base of transverse membranous tumors is generally small, and the tumor wall is relatively intact. When we design the placement position of blocker, the base is preferred. However, when the rupture is far from the base or the upper edge of the base is close to the aortic valve, the rupture can also be blocked. Since the aneurysm is transversely flat, the resistance to pulling the plugger into the aneurysm is relatively high, so after the left disc of the plugger is in place, the delivery cable should be pulled moderately. This procedure can be performed under ultrasound instructions to prevent the rupture opening from widening or the blocker from dislodging into the right ventricle due to excessive pulling. Ruptured transverse septal membrane tumor is a special form of membrane tumor rupture, and interventional occlusion can be successfully performed by adopting the appropriate operation method according to its morphological characteristics. Reference.