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

2. 1 、 The number and quality of VSD intervention improved during past ten years

3. The first pmVSD patients treated with symmetric occluder (2001.12 ， 21) The first post-MI VSD patient treated with symmetric occluder (2001.10) The first cases of VSD intervention in our center

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

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

6. VSD intervention in last 3 years in China （ 394 hospitals ） 200920102011 total160451867122967 ASD552767938089 PDA470554664075 VSD 352142525474 PBPV603680905 Success rate97.24%97.67%98.11% Complication0.2%0.17%0.12% Mortality0.03%0.05%0.02%

7. 2 、 Three kind of VSD devices invented and clinical use in China

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

9. Schematic diagram of ventricular septal defect occluder

10. 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

11. Infundibular VSD symmetric occluder

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

13. Intracristal VSD

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

15. Intracristal VSD

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

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

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

20. PV VSD Echo: subpulmonary VSD---near PV

21. VSD complicared with aortic valve prolapse

22. VSD 5mm ----- 0 rim device (10mm)

23. Postoperation, no aortic regurgitation However, occluder maybe oversized

25. VSD 7mm, near aortic valve

27. Echo: subpulmonary VSD---near PV

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

29. no aortic valve regurgitation

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

32. One device close three holes

33. VSD2 VSD1 device For VSD2 VSD1 VSD with two holes

34. Two device for two holes

35. Large VSD -1

36. Large VSD -2 14mm A6B2 device

37. Large VSD -3 No aoric valve regurgitation,no TVR

38. PDA device for large VSD

39. 20mm PDA device

40. PDA device for large VSD

41. post-myocardial infarction VSDmuscular occluder Post-myocardial infarction VSD

43. Postoperative residual perimembranous VSD Transcatheter closure of postoperative residual perimembranous VSD

44. PS and large VSD VSD 17mm, device 24mm

45. 3 、 Conduction Block complicated with VSD Intervention: experience in china

46. anthorsampleAVB%cAVB%PPMonsetrecovery Song et al 328 27(8.2%) 8012h-614-20d Xie et al 644 16(2.5%) 623-6d8-10d Wang et al 364 20(5.5%) 403-14dNA Zhang et al 232 17(7.3%) 1204-6d4-27d Wu et al 112 22(19.6%) 005d Zhu et al 358 23(6.4%) 501-8d6-10d Liu et al 210 41(19.5) 617d21d Yu et al 112 37(33%) 803-9d3-7d Qin et al 203 11(5.4%) 102-5d5-10d Past Literature Review in China

47. Clinial trial data of Amplatzer VSD device Catheter Cardiovasc Interv. 2006, 68(4):620-8. (n=100) J Am Coll Cardiol. 2006, 47(2): 319-25. (n=35) Eur Heart J. 2007, 28: 2361. (n=430) N: 565 Success rate 91-95 ％ 3rd AVB 2-8 ％ PPM 12 (3.8 ％ ) death1

48. 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)

49. 2011 registry data in China 5474 cases with vsd in 394 hospital in china PPM 1case

50. The data from Changhai hospital (2001-2012) 2001-2002, 196 cases underwent percutaneous procedure (using symmetry device), no cAVB 2003-2006, among 300 cases (Symmetry, Eccentric 、 thin waist devices), 11 cases complicated transient 3rd degree AVB, permanent pacemaker occur in 1 case 2007-2012, sequence 550 cases with Symmetry, Eccentric,thin waist devices, cAVB occur 1 patient

51. 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

52. Device waist length and AVB 2001--2003---more than 3.5 mm---no case with AVB 2003--2006---less than 2.5mm---12/300 with AVB 2007--2012---more than 3.5mm---no case with AVB

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

54. 3 rd AVB

55. 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

56. 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

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

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

59. 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

60. Large VSD (22mm) Wire-Maintaining Technique

61. 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!

62. Thank you