Surgically-BasedDevice VSD Closure Olaf Wendler Department of Cardiothoracic Surgery King‘s College Hospital

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Conventional Surgical Treatment Background Early clinical outcome after surgical repair of acute ischemic VSD is poor (mortality 30-50%) - Cardiogenic shock - Recurrent VSD - Complications from prolonged ITU 1. Jeppsson A et al. Eur J Cardio-thorac Surg Jeppsson A et al. Eur J Cardio-thorac Surg David TE et al. J Thorac Cardiovasc Surg David TE et al. J Thorac Cardiovasc Surg 1995

Interventional VSD-Closure Device closure is established as an option Device closure is established as an option for VSD closure in paediatric patients for VSD closure in paediatric patients Case series of ischaemic VSD’s reported Case series of ischaemic VSD’s reported Interventional VSD-Closure N=18, 5 pts with acute iVSD, early survival 40%

Hypothesis Hypothesis for Pilot Trial Direct surgical closure of an acute iVSD using an VSD device toDirect surgical closure of an acute iVSD using an Amplatzer ® muscular VSD device to Reduce cardiac traumaReduce cardiac trauma –Avoid left ventriculotomy –Reduce CPB time –Avoid cardiac arrest Achieve full revascularisationAchieve full revascularisation Reduce incidence of recurrent VSDReduce incidence of recurrent VSD Simplify device deploymentSimplify device deployment (Ethically approved by the King’s Novel Procedures Committee) (Ethically approved by the King’s Novel Procedures Committee)

Case Report A novel surgical approach to close an acute ventricular septal defect using an occluder device Chanaka Rajakaruna (MRCS), Jonathan Hill (MA, MRCP), Eleanor Jane Holland Turner (BSc, PhD, MRCS), Alex Sirker (MRCP), Bushra S Rana (MRCP), Olaf Wendler (MD, PhD, FRCS) Departments of Cardiothoracic Surgery and Cardiology, Kings College Hospital, London. UK.

Case Report 75 y, male no past medical History Presentation – –Anterior MI – –iVSD 4 d pMI – –Pulmonary oedema – –Cardiogenic shock Patient Data

Case Report ECHO Anterior VSD (7-9 mm)Anterior VSD (7-9 mm) L to R shunt (Qp:Qs = 4:1)L to R shunt (Qp:Qs = 4:1) LVEF 45%LVEF 45% RV preservedRV preserved PAP 50 mmHgPAP 50 mmHg

Case Report Preoperative Treatment Insertion of IABPInsertion of IABP Coronary angiographyCoronary angiography –LAD 95%, D1 75% –Cx normal –RCA occluded, Crux 70% Scheduled for surgery when he deterioratedScheduled for surgery when he deteriorated 10 pMI ( ).

Case Report Operation (I) Midline sternotomy & aorto-bicaval cannulationMidline sternotomy & aorto-bicaval cannulation On-pump beating heartOn-pump beating heart –Sequential LIMA to LAD & D1 –Sequential SVG to LV branch & PDA Epicardial 3-D-ECHOEpicardial 3-D-ECHO –VSD of mm in the mid septum

Case Report Operation (II) VF induced Incision (1.5cm) in the anterior wall of the RV VSD size 20mm, Device 24mm Device deployed, direct vision RV closed after de-airing The patient weaned off CPB with IABP and Noradrenaline (0.09mcg/kg/hr)

Case Report Postoperative Course Early extubation (6 hours pOP)Early extubation (6 hours pOP) IABP for 48 hoursIABP for 48 hours Furosemide infusion (5-10mg/hr)Furosemide infusion (5-10mg/hr) Adrenaline and Noradrenaline ( mcg/kg/hr)Adrenaline and Noradrenaline ( mcg/kg/hr) ComplicationsComplications –Chest infection –Haemothorax secondary to chest drain (day 20) Discharged on day 32Discharged on day 32

Case Report 6 - Months Follow-Up AsymptomaticAsymptomatic NYHA INYHA I ECHOECHO - Device well seated - Residual shunt through device through device (Qp:Qs=2:1) (Qp:Qs=2:1) PAP 20 mmHgPAP 20 mmHg

Summary Summary Potential advantages vs. Conventional surgery Conventional surgery - No incision in the LV - No incision in the LV - Reduced CPB time - Reduced CPB time - No cardiac arrest - No cardiac arrest Interventional treatment Interventional treatment - Device deployed under direct vision - Device deployed under direct vision - Complete revascularization - Complete revascularization

Conclusion Conclusion Limitation - Residual shunt through the device - Residual shunt through the deviceOutlook - Earlier intervention may improve outcome - Earlier intervention may improve outcome - Improve surgical technique - Improve surgical technique - Modification of the device - Modification of the device