Update of Transcatheter Closure of Ventricular Septal Defect in China Yong-wen Qin Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai

1 、 The number and quality of VSD intervention improved during past ten years

The first pmVSD patients treated with symmetric occluder ( ， 21) The first post-MI VSD patient treated with symmetric occluder ( ) The first cases of VSD intervention in our center

Large VSD closure in 2002 large VSD (15mm) closed by 18mm occluder

Development of CHD intervention from 1990s-2011 in China year Patient number *

VSD intervention in last 3 years in China （ 394 hospitals ） total ASD PDA VSD PBPV Success rate97.24%97.67%98.11% Complication0.2%0.17%0.12% Mortality0.03%0.05%0.02%

2 、 Three kind of VSD devices invented and clinical use in China

Modified VSD device in China symmetric occluder thin waist occluder asymmetric occluder

Schematic diagram of ventricular septal defect occluder

The classification of VSD by ventriculography A tubular B window-like C aneurysmal D infundibular Individualization choice of the occluder according to anatomy of VSD

Infundibular VSD symmetric occluder

How to choose the occluder according to VSD Intracristal VSD asymmetric occluder

Intracristal VSD

Symmetric device ---Aortic valve regurgitation asymmetric device ---no aortic valve regurgitation

Intracristal VSD

Aortic valve regurgitation--- device inclined to one side The direction of left disk marker should be apex

Intracristal VSD When the marker turn to apex, aortic valve regurgitation became trace

Intracristal VSD No aortic valve regurgitation-- long rim direction pointed to cardiac apex

PV VSD Echo: subpulmonary VSD---near PV

VSD complicared with aortic valve prolapse

VSD 5mm rim device (10mm)

Postoperation, no aortic regurgitation However, occluder maybe oversized

VSD 7mm, near aortic valve

Echo: subpulmonary VSD---near PV

Device 9mm (L), change to Device 11mm (R)

no aortic valve regurgitation

Multi-hole VSD---device choice multi-hole VSD thin waist occluder

One device close three holes

VSD2 VSD1 device For VSD2 VSD1 VSD with two holes

Two device for two holes

Large VSD -1

Large VSD -2 14mm A6B2 device

Large VSD -3 No aoric valve regurgitation,no TVR

PDA device for large VSD

20mm PDA device

PDA device for large VSD

post-myocardial infarction VSDmuscular occluder Post-myocardial infarction VSD

Postoperative residual perimembranous VSD Transcatheter closure of postoperative residual perimembranous VSD

PS and large VSD VSD 17mm, device 24mm

3 、 Conduction Block complicated with VSD Intervention: experience in china

anthorsampleAVB%cAVB%PPMonsetrecovery Song et al (8.2%) 8012h d Xie et al (2.5%) 623-6d8-10d Wang et al (5.5%) dNA Zhang et al (7.3%) d4-27d Wu et al (19.6%) 005d Zhu et al (6.4%) 501-8d6-10d Liu et al (19.5) 617d21d Yu et al (33%) 803-9d3-7d Qin et al (5.4%) 102-5d5-10d Past Literature Review in China

Clinial trial data of Amplatzer VSD device Catheter Cardiovasc Interv. 2006, 68(4): (n=100) J Am Coll Cardiol. 2006, 47(2): (n=35) Eur Heart J. 2007, 28: (n=430) N: 565 Success rate ％ 3rd AVB 2-8 ％ PPM 12 (3.8 ％ ) death1

The data on VSD occluder in China from 21 centers (N=9311, 2007) Success rate 96.45% Death 0.05% (5) Transient cAVB 0.63% (59) PPM 0.09% (8)

2011 registry data in China 5474 cases with vsd in 394 hospital in china PPM 1case

The data from Changhai hospital ( ) , 196 cases underwent percutaneous procedure (using symmetry device), no cAVB , among 300 cases (Symmetry, Eccentric 、 thin waist devices), 11 cases complicated transient 3rd degree AVB, permanent pacemaker occur in 1 case , sequence 550 cases with Symmetry, Eccentric,thin waist devices, cAVB occur 1 patient

The possible reason of increase AVB from 2003 to 2006 ? Patients: patients non-selected, consecutive patients admitted Doctors: personnel stability, and operation technology maturity Indication: increased intracristal multi-holes and aneurysm type VSD Devices: Application of asymmetric occluder

Device waist length and AVB more than 3.5 mm---no case with AVB less than 2.5mm---12/300 with AVB more than 3.5mm---no case with AVB

Chinese device shape at immediate compared with amplatzer devices amplatzer devicesShape change AVB device shape at immediate

3 rd AVB

My opinion is that device is key factor for conduction block.  Device tension---flex  Contact area with the septal  Size --- waist diameter  Length of waist The risk factor of AVB

Choose the proper device size Avoid oversized device AVB seems to be fewer in symmetric occluder. “Nice” occluder Individualized choice of occluder for pts Very experienced hands Major success experience on prevention of AVB

Other Risk factors for the Occurrence of AVB Type of VSD: perimembranous VSD inlet VSD (behind the septal leaflet of tricuspid valve)

The VSD intervention is safe, effective and an alternative method to surgery or first choice in China

Wire-Maintaining Technique Using this novel technique, the reconstruction of ‘‘arteriovenous wire loop’’ could be avoided in patients requiring device replacement. QIN, et al. CCI 75:66 – 71 (2010) 4 、 Useful technique in intervention of VSD

Large VSD (22mm) Wire-Maintaining Technique

How to choose the patient for VSD closure- ---TTE three views the apical 5-chamber view LV long axis l view Aortic short axis view Compared to TEE, TTE is enough!

Thank you