Brig Gen (Prof) Nurun Nahar Fatema MBBS, FCPS (Paed), FRCP (Edin), FACC (USA), FSCAI Advisor Pediatrics , BAF Interventional Paediatric Cardiologist, CMH Dhaka.
Introduction & Background
- Congenital heart disease is not very uncommon in our country.
- Incidence worldwide is 8/1000 live birth
- About 40% of them are contributed by atrial and ventricular septal defects and patent ductus arteriosus.
- Idea of doing device closure is to avoid mental and physical stress of the patient and parent in these huge number of cases by avoiding a major surgery.
- Population – 163 Million
- Area – 1;47570 sq km
- Per capita income – 1524 Us $
- Cardiac Centers – Ten
- Closure of shunt anomalies(all age group) has been started in one centre (CMH DHAKA) since September 1998 and in other center of Bangladesh since 2009 0nwards slowly.
- Incidence of CHD in a Bangladeshi center is 25/1000 live birth.
Device Price Appoximate
- PDA device – 800-1200 US$
- ASD device – 1000- 2300 US$
- VSD device – 1000 -2300 US$
Problems of doing device closure
- Expensive, most of the patient can not afford
- Difficult to convince patient as technology is new
- Less knowledge about device closure and its consequences
- Doubt about long term outcome/ prognosis/complications.
Device options for shunt anomalies and others
- Patent Ductus Arteriosus
- Secundum Atrial Septal Defect
- Ventricular Septal Defect
- Aortopulmonary window
- Blalock Taussig shunt
- Patent foramen ovale
- Coronary artery venous fistula
Atrial Septal Defect (ASD) Device Closure
- First ASD device closure was done by King & Mills in 1976.
- First ever ASD Device closure in our country was done in the year 2000 at CMH Dhaka.
Indication for ASD Device closure
- Any ASD secundum with rim of 5 mm
- Body weight > 8kg
- Evidence of right ventricular overload
Other Options for ASD Closure
Complication of ASD closure
- Pericardial effusion
- Aortic erosion
- Complete heart block
ASD device closure 18 mm occluder
Large ASD device closure by 14mm occluder
Patent Ductus Arteriosus (PDA)
- First PDA device closure is done by Postmann et al in 1967.
- First ever PDA coil occlusion in our country is done in the year 1998 at CMH Dhaka.
Indication for PDA device closure
- Large PDA with features of heart failure or uncontrolled failure in young infant.
- Haemodynamically significant PDA diagnosed after 3 months of age.
- PDA with PAH
Note: Silent PDAs are not closed
Duct Occluder I and II
Other implants for PDA Closure
- Gianturco Coils
- Detachable coils (Cook, Jackson)
- Riedel Coil
- Grifca beg
- Cardio seal
- PFM coil.
- Star flex device.
- ADO II
Complications of PDA device closure
- Device embolization
- Vascular injury
- Intravascular Hemolysis
- Residual shunt
PDA device closure in 2.4 kg infant with Rt femoral vein stenosis.
PDA device closure (ADO II)
PDA coil occlusion
PDA device closure by 10×8 mm Occluder
Ventricular Septal Defect (VSD) Closure
- First VSD device closure is done by Lock et al in 1988.
- First ever VSD Device closure in our centre in 2005 (muscular), in 2006(Perimembranous) , in 2007 (by coil) & in 2012 (by ADO II).
Indication for VSD device closure
- All muscular VSD
- All perimembraneous VSD with minimum 2 mm distance from aortic valve
- Post MI VSD
VSD occluder devices
Other Options for VSD Closure
- 1. Rashkind device
- 2. Clamshell device
- 3. Sideris device
- 4. VSD OS
- 5. Cardio SEAL
- ADO I
- ADO II
- PFM coil
Complication of VSD closure
- Complete heart block
- Pericardial effusion
VSD Device closure by ADO II device
DC VSD closure by Amplatzer device
PM VSD closure by Amplatzer device
Sub aortic VSD closure by Amplatzer device
Muscular VSD closure by Amplatzer device
VSD closure by Coil Occlusion 5×4 mm
Other lesions amenable to device closure in our Centre
- Coronary fistula with AVP
- Arterio venous fistula
- BT Shunt
- Closure of ASD and PDA is associated with minimal haemodynamic disturbances and performed as out patient basis under sedation.
- VSD device closure are often associated with major haemodynamic disturbances and we perform them as inpatient basis and keep them admitted for 72 hours after intervention for classical device and 24 hours for off label use of ADO II device.
- Care of puncture site and sedation till stabilization. ECG after 12 hours for ASD and VSD cases.
FOLLOW UP AND ANTICOAGULATION
- Echo performed in next morning before discharge. Appointment given at 1, 3 ,6 ,9 ,12 ,18 ,24 months and yearly there after for two years.
- CXR, ECG and Echo were done in every follow up.
- Aspirin is adv for 6 months and 1 months for ASD and VSD cases, For PDA Aspirin not reqd.
To show the outcome of Device closure of shunt anomalies in our center.
- Retrospective study .
- Place ; CMH Dhaka & Labaid Cardiac Hospital Dhaka.
- Study period: Sep 1998 to Sept 2017
- Total patient – 3993 (Echo selection)/3812 (Cath selection)
- Any patient who fulfilled the Echocardiographic criteria for Device closure
- For ASD – secundum type with minimum rim of 5mm
- All muscular VSD,s and selective Perimembranous VSD with minimum distance of 2mm from aortic valve
- PDA of any size and any age.
- ASD, VSD or PDA associated with other complex cardiac lesions.
- ASD other than secundum type.
- Perimembranous VSD with inlet or outlet extension . ( but some of the doubly committed VSD were accepted).
Primary and Final selection for Device Closure (n= 3993)
Selection of individual type for device closure (n=3812)
AGE DISTRIBUTION PDA
Sex Distribution PDA
AGE DISTRIBUTION ASD
Sex Distribution ASD
AGE DISTRIBUTION VSD
Sex Distribution VSD
OUTCOME OF PDA CASES
OUTCOME OF ASD CASES (n=1258)
OUTCOME OF VSD CASES N=526
Double intervention in single setting (n=151)
Exception in our center
- Closure of large tubular PDA with severe PHT
- Device closure with off label use of ADO II in retrograde approach (1st performed in our center in the year 2012.
- VSD closure with coil (with Cook coil).
- We follow minimalistic approach in intervention with cocktail sedation and Transthoracic echocadiographic guidance routinely unless critical situation arise.
Statistic of device closure for CHD in other centers of Bangladesh
Cause of postponding cases after selection
- 7 cases
- Azygous continuation IIVC, 3 cases,
- Femoral vein stenosis 1 cases
- Development of Eisenmenger syndrome 3 cases.
- Out of 1398 cases 140 cases were postponed.
- Too large ASD in comparison to IAS after balloon sizing.
- Out of 560 VSD cases 34 cases had been postponed
- Failure of stable position of wire in 3 cases,
- Neo aortic regurgitation in 15 cases,
- Encroachment of aortic valve in 5 cases,
- Encroachment of tricuspid valve in 2 cases,
- Failure to cross VSD in 2 cases and
- Development of arrhythmia in 5 cases).
Conclusion( in 2005)
- Device closure of shunt anomalies are fascinating both for the patient and for the cardiologist. Parents don’t want a scar in their child’s chest wall. So procedure is gaining popularity rapidly.
- It is likely that during the next five to ten years a number of improvement in device design will come up with increasing clinical experience, which will produce a further shift of data towards non surgical closure of shunt anomalies with various devices.
- At the same time a well trained, experienced pediatric cardiology team is a must for doing these interventions.
- Many centers are coming up with device closure technology in recent years and hopefully number of cases will be increased significantly in coming years.
- Team approach is important for these interventions to get outstanding outcome . Good echocardiographer is must to bring reqd view.
- Reuse of long delivery system should be discouraged for patients safety.