Abstract 2453: Transcatheter Creation and Enlargement of Ventricular Septal Defects for Relief of Ventricular Hypertension in Patients with Complex Congenital Heart Disease
Introduction Transcatheter creation of a therapeutic VSD, previously unreported, may be indicated in rare clinical situations. In the setting of DORV requiring single ventricle palliation, LV outflow obstruction due to progressive restriction at the VSD poses an uncommon dilemma. The isolated LV becomes hypertensive and hypertrophied and may be prone to arrhythmia or aneurysm formation. In this situation, surgical VSD enlargement may be desirable, but risks damage to the atrioventricular valve (AVV) or conduction system. We report the results of a novel technique for transcatheter creation or enlargement of VSDs as an alternative to reoperation when decompression of an isolated ventricle is indicated.
Methods We reviewed the results of transcatheter VSD creation in patients with DORV and restrictive VSD or similar physiology. VSDs were created by use of a telescoping system of a shaped catheter and long sheath directed to the midmuscular septum of the hypertensive ventricle. The septum was cross with the stiff end of a wire, a soft-tipped wire was passed and the VSD was dilated and/or stented. VSD enlargement employed a similar technique with use of a soft-tipped wire.
Results Seven patients were identified. Two patients had undergone 3 prior surgical attempts at LV decompression. Ventricular aneurysms had developed in 3 patients. At the initial procedure 4 patients underwent VSD creation and 3 patients underwent enlargement of existing VSDs. Initial intervention resulted in a decreased VSD pressure gradient from 73.3mm Hg to 17.3mm Hg (p=0.03). There was no procedural mortality or heart block. Two patients developed moderate-severe AVV regurgitation, one required surgical repair. At last follow up (range 14d - 9yr), all VSDs remained patent, with recurrent obstruction in the majority of cases due to muscular hypertrophy beyond the stent margins. No stent fractures were identified. In one patient a ventricular aneurysm has regressed in size. Repeat intervention reduced recurrent obstruction but recurrence was invariable.
Conclusions When reoperation is considered high risk, transcatheter creation and enlargement of VSDs is possible with excellent short-term results. Recurrent obstruction is common but responds to repeated intervention.