Unplanned Surgery After Transcatheter Closure of Ventricular Septal Defect in Children: Causes and Risk Factors

Abstract

Objectives: To evaluate the causes and risk factors of unplanned surgery after transcatheter closure of ventricular septal defect (VSD) in children.Methods: A total of 773 patients with VSD who had the devices transcatheter released between January 2013 and December 2018 in our institution were retrospectively reviewed. Univariate and multivariate analyses were used to identify the risk factors for unplanned surgery.Results: Twenty four patients (3.1%) underwent unplanned surgery after transcatheter closure of VSD. The most common cause for unplanned surgery was new-onset or worsening aortic regurgitation (14/24; 58.3%), followed by occluder migration (4/24; 16.7%), complete atrioventricular block (2/24; 8.3%), severe hemolysis (2/24; 8.3%), residual shunt (1/24; 4.2%), and occluder edge near the tricuspid valve chordae (1/24; 4.2%). Logistic regression analysis revealed that primary aortic valve prolapse (OR: 5.507, 95%CI: 1.673–18.123, P = 0.005); intracristal VSD (OR: 8.731, 95%CI: 2.274–33.527, P = 0.002); eccentric occluder (OR: 4.191, 95%CI: 1.233–14.246, P = 0.022); larger occluder size (OR: 1.645, 95%CI: 1.331–2.033, P < 0.001); and pulmonary artery systolic pressure ≥45 mmHg (OR: 4.003, 95%CI: 1.073–14.941, P = 0.039) were risk factors for unplanned surgery.Conclusions: New-onset or worsening aortic regurgitation was the primary cause for unplanned surgery after transcatheter closure of VSD in children. Primary aortic valve prolapse, intracristal VSD, eccentric occluder, larger occluder size, pulmonary artery systolic pressure ≥45 mmHg could increase the risk of unplanned surgery.

Word of caution: Severe aortic valve injury linked to retrograde closure of perimembranous ventricular septal defects

“…9 Likewise, several reported cases were resulting from an occluder pinching on the valve leaflets or a cusp perforation by the wire, catheter, or sheath. [3][4][5] Early recognition and management of this complication are crucial. Although iatrogenic aortic valve injury is commonly recognized during the intervention and so can be immediately treated, this complication may appear several years later with progressive AR.…”

“…3,10 Left ventriculography after sheath placement can be considered to better reflect the relationship between the defect and the aortic valve because the sheath will hold up the aortic valve. 3 Eccentric membranous occluders can be also considered as potential alternatives to avoid measurement errors in optimistic ultrasound evaluation. However, AR still occasionally occurs in recent studies.…”

“…However, AR still occasionally occurs in recent studies. 3 Aortic valve prolapse is intimately linked to the occurrence or worsening of AR. 11 This is because the process of repeatedly pressing the distal part of the delivery sheath into the LV would increase the risk of valve injury.…”

“…Technical and anatomical challenges are numerous leading to increasing attention to the adverse events of this procedure 1–3 . Aortic valve injury can seldom occur but is a major complication leading in most cases to an unplanned open‐heart surgery 3–5 . KONAR‐MF™ VSD occluder, also known as multifunctional occluder (MFO) (Lifetech) is a double‐disk device with particular characteristics.…”

“…Device closure of perimembranous ventricular septal defects (pmVSDs) remains a debatable catheter‐based intervention in some centers 1 . Technical and anatomical challenges are numerous leading to increasing attention to the adverse events of this procedure 1–3 . Aortic valve injury can seldom occur but is a major complication leading in most cases to an unplanned open‐heart surgery 3–5 .…”