SHA24/059001

Successful Closure of PM VSD with Inlet extension using ADO1 Mashail Alobaidan Consultant Interventional Pediatric Cardiology, PSCC 10th GHA , 24th SHA 13-16-February 2013

Location of VSDs • Perimembranous (membranous/ infracristal )70-80%

Indication for closure • • • •

Large Shunt Elective…… ( LVE ? Point of no return) Prevention of endocarditis Symptoms

Morphology of the defect  Presence of aneurysm…  Separation of the defect from aortic valve  Presence of AOV prolapse  Extension to the inlet

Device Choice  Presence of aneurysm…ADOI & Nit Occluder  Absence of aneurysm …double disk design)

Size of the defect  ADO II up to 5.5 mm  Nit Occluder up to 8 mm.  ADO I up to 12 mm  APM VSD & AMVSD Occluder up to 16mm.

Distance from aortic valve  <4 mm : APMVSDO and Nit Occluder  >4 mm : ADO I, ADO II, AMVSDO, Symmetric Devices

Extension into the inlet  Use a device with minimum clamp force..

Nit Occluder or single disc design ( ADOI)  Devices with wider waist ( ADO II, AMVSDO, Modified devices)

Type of Devices

Approach • • • • • •

Clinical & echo evaluation General anesthesia vs. conscious sedation TOE and angio. to assess VSD Cross VSD from LV or RV Balloon size ??

Device choice

Amplatzer Pm VSD Device Muscular VSD device modified in order to adapt to membranous septum anatomy 2002 -- Eccentric LV disk with almost no aortic edge -- Shorter central part ( 1.5 mm) -- Less stiff ( 0.003-0.005 nitinol wire) -- Directional delivery system

Amplatzer Pm Device 1  2002-2005: Initial results very encouraging  Successful implantation =95-100%  Complete Occlusion at 6 months= 95-100%  No infection  Uncommon AI or TR

Amplatzer Pm Device1 • 2006 : Result became worrisome • CAVB in around 5% • Can appear after 3 yr post-procedure

• Risk factor :

• Young and small pt.

• Posterior or high muscular extension of Pm.VSD • Absence of aneurysm • Oversizing of the device • Device probably too rigid ( radial force ) and narrow( clamp force)

Amplatzer Membranous Occluder 2 • New unique device design to minimize the pressure on the ventricular septum • Larger waist length=reduces clamp force • Waist made with a dual layer of nitinol wire braid ( including a softer outer layer)= minimize radial pressure against the defect while providing equal or increased stability  World’s first implant June 2011

Devise stability Concave LV disc provide stability resistance to pull through during implantation

Other features

Prince Sultan Cardiac Center Experience Prince Sultan Cardiac Center Experience

Mashail Alobaidan, MD , Abdulmajeed Alotay, MD, Abdullah Algahtani, SCF PSCC, Riyadh, Saudi Arabia 10th GHA , 24th SHA 13-16-February 2013

Prince Sultan Cardiac Center Experience Total of 5 patients between July 2011 and February 2012 in PSCC Median age is 7 year.

Median weight is 17 kg.

Female: Male ratio is 3:1 Follow up is 16 month.

Patients characteristics

Method • • • • • • • •

All patients were evaluated by TTE before procedure 3 patients were with weight < 3rd percentile for age 1 patient with both exercise intolerance and poor weight gain All with LVEDV > upper normal 2 patients with moderate TR All patients were consented Procedure were done under general anesthesia except one.

Transesophageal echocardiography was done in 4 .

Method • • • • •

one has 3D assessment .

Haemodynamics were assessed pre procedural , A-V loop was achieved in 3 patients .

ADO I were used in all .

Heparin and antibiotics were giving during and 24 hrs. post procedure , • 3 patients were extubated same night and one the following day.

• All patients were kept on aspirin for 6 months.

Result • • • •

Median Ventilatory duration is 1 day Median hospital day is 2 days No immediate or early complication or deaths Normal ECG immediately and during follow up period • Echocardiography with no residual leak or progression of TR on discharge and during follow up period.

Haemodynamics

Result

Pre and Post Procedural TR and AI

Conclusion • Transcatheter closure of all type of VSDs is feasible • It is preferable to use the specifically designed devices • Wide range of devices are available.

• Comprehensive imaging is mandatory • In selected patients with PM VSD and inlet extension ADO I device can be used safely and effectively to close the defect with no immediate or early complications (Larger waist length=reduces clamp force) • Intervention experience is essential

Thank you very much DR. Mashail Alobaidan