Overview of Catheter Management of Ventricular Septal Defect
A ventricular septal defect (VSD) is a type of heart condition that a person can be born with (congenital). It’s the most common heart issue in children and the second most common in adults, after bicuspid aortic valves (which is another heart condition). A VSD happens when there is a hole in the wall (called the septum) that separates the heart’s lower chambers (called the ventricles).
Interestingly, many VSDs can resolve on their own, but not all do. When a VSD doesn’t close naturally, it can cause problems with the heart’s function, which doctors call ‘hemodynamic compromise’. This means the heart isn’t able to pump blood as efficiently.
The treatment for a VSD depends on its size and how much it affects the heart’s function. For smaller VSDs that aren’t causing any symptoms or issues, doctors might just keep an eye on it. But for larger VSDs that are causing problems, surgery might be recommended.
In the past, VSDs were typically treated with open heart surgery. However, a new, less invasive method has been introduced: the percutaneous transcatheter closure. This procedure involves threading a thin tube into the heart to correct the defect. This is mostly used when a person can’t have traditional surgery. The first time this particular procedure was done was back in 2013.
Therefore, it’s important to remember that even though a VSD could potentially be serious, medical science has evolved and continues to find better ways to treat this condition.
Why do People Need Catheter Management of Ventricular Septal Defect
The American Heart Association and American College of Cardiology suggest some guidelines for when a person might need to fix a hole in their heart, known as a ventricular septal defect (VSD). The suggestions include:
1. If there’s too much blood in the left side of the heart, and this extra volume is causing significant shunting – a term for when the blood takes detours from its normal path (usually more than 1.5 times usual), they should get the hole closed. This should happen only if the pressure in their lung artery is less than half of the usual, and the resistance in the lung’s blood vessels is less than a third of normal.
2. Adults with a hole near the heart’s membrane, or above a feature called the crista supraventricularis, may consider closure if they are experiencing increased backflow in their aorta, which is a major blood vessel. The backflow, or aortic regurgitation (AR), happens because of the defect.
3. Adults who have had a heart infection due to a VSD might consider fixing the hole, if they have no other conditions that would make it dangerous.
Other individuals who might consider closing their VSD are those with significant blood shunting, but whose lung artery pressure or lung vessel resistance is significantly higher.
Surgical closure of a VSD is currently the suggested method. However, for those unable to have surgery, a method called percutaneous transcatheter VSD closure is recommended. This alternative also works well for individuals worried about abnormal electric signals, referred to as conduction abnormalities, in the heart.
When a Person Should Avoid Catheter Management of Ventricular Septal Defect
The American Heart Association and American College of Cardiology have specific guidelines about a medical condition known as Ventricular Septal Defect (VSD). VSD is a hole in the wall separating the two lower chambers of the heart. Sometimes, doctors need to close this hole with a procedure but it’s not always safe for everyone.
Adults with severe Pulmonary Arterial Hypertension (PAH) – a type of high blood pressure that affects the arteries in the lungs and on the right side of heart – should not have this procedure. This especially applies if the pressure in their pulmonary artery – the large blood vessel carrying oxygen-poor blood away from the heart to the lungs – is more than two-thirds of the body’s normal systemic pressure or if their pulmonary vascular resistance, which measures how hard it is for blood to flow through the lungs, is more than two-thirds of what it should be in the body’s circulatory system. They also should not have the procedure if they have a net right-to-left shunt, which is a condition that causes blood to flow from the right to the left side of the heart.
Who is needed to perform Catheter Management of Ventricular Septal Defect?
To successfully treat a VSD (a hole in the heart) using a method called percutaneous catheterization, it takes a team of healthcare professionals. This includes an interventional/structural cardiologist (a heart doctor who uses specific techniques to correct heart problems), a pediatric cardiologist (a heart doctor for children), an anesthesiologist (a doctor who’s in charge of making you sleep during the procedure), a cardiothoracic surgeon (a special kind of surgeon who operates on the heart and chest), a radiologist (a doctor who uses medical imaging techniques), and other hospital staff members. All these people work together to make sure your treatment is successful.
Preparing for Catheter Management of Ventricular Septal Defect
Before undergoing a procedure to close a hole in the heart (known as a Ventricular Septal Defect or VSD), a patient is required to go through a series of checks to make sure they’re suitable for the procedure. The common test doctors prefer is the transthoracic echocardiogram, which checks the size and location of the hole in the heart. Also, important is the cardiac catheterization that checks for high blood pressure in the lungs, called pulmonary hypertension. Other tests may include chest X-rays, electrocardiograms (heart rhythm tests), and blood tests to check if the patient is in good health as well as to examine the function of their kidneys.
Before the heart hole closure procedure, preventive measures are taken to avoid unwanted blood clots. Patients are usually given medication, such as aspirin and clopidogrel, on a daily basis. If not, warfarin could be an alternative, used along with a specific type of blood-thinning medicine (low-molecular-weight heparin) before and after the procedure.
Also, to help prevent infection, an antibiotic (typically cefazolin or, if the patient is allergic to penicillin, vancomycin) should be administered via IV (intravenous drip) one hour prior to the procedure. Alongside this, patients are often given a saline drip to help avoid insufficient blood volume in the left atrium of the heart during the procedure.
Every patient requires an assessment by an anesthesiologist before the procedure. For patients under 10 years old, general anesthesia (complete sedation) is the usual choice, while for those above 10, a more mild type of sedation that allows them to remain awake but relaxed is often used.
How is Catheter Management of Ventricular Septal Defect performed
If a doctor needs to evaluate a hole in the heart (known as a Ventricular Septal Defect or VSD), they might do a procedure called a catheterization. During this procedure, the doctor will insert a thin, flexible tube (catheter) into a vein and an artery in your groin area (right femoral vein and right femoral artery). They will then use a special type of x-ray (angiographic evaluation) to clearly see the hole’s location, size, and how it’s related to one of the heart valves (aortic valve). The doctor will measure the hole at a specific point in the heartbeat cycle known as the diastolic phase. The method used to close the hole will be chosen based on the type and size of the hole.
If the hole can be treated, a loop is created between an artery and a vein (arteriovenous circuit). Once they’ve picked the right tool to close the hole, a slightly larger tube (5 Fr catheter) is moved from the lower left chamber of the heart (LV) across the hole. They’ll then move a longer tube (6 to 12 Fr) into the LV passing through the loop and position it below the aortic valve. The doctor uses this longer tube to place the tool that will close the hole, watching on an x-ray and echocardiogram (ultrasound of the heart) to guide them.
X-ray imaging of the LV and the part of the aorta leaving the heart is done to make sure the hole is completely closed and to check that there’s no new issues with the aortic valve. After the procedure, patients should stay in the hospital for 24 hours for continuous heart rhythm monitoring as this is the time when irregular heartbeats (arrhythmias) most commonly occur. All patients should also take aspirin (5 mg/kg daily) to decrease the chance of blood clots forming (thromboembolism).
Possible Complications of Catheter Management of Ventricular Septal Defect
Using a catheter to fix a hole in the wall of the heart (ventral septal defect) can have several problems:
The main complication is having abnormal heart rhythms (arrhythmias). There’s about a 4.6 to 17 in 1000 chance of experiencing these after the device is put in your heart. Most of these issues occur within the first week, but sometimes they can even happen during the operation itself. Some commonly seen abnormal rhythms include right bundle branch block (6.4% chance), left bundle branch block (1.6% chance), fast heart rate (3.2% chance), and a second type of atrioventricular block (1.09% chance). The chance of needing a pacemaker is about 3.8%. It’s also worth noting that depending on the type of hole in your heart, you might be at a higher risk for certain types of abnormal heart rhythms.
Another complication is something called a trivial residual shunt. This occurs when there’s a small amount of blood that bypasses your lungs and enters your bloodstream directly. This can happen in about 5 to 6.7% of patients.
Issues with your heart valves can also happen after getting a VSD closure device. For instance, there’s about a 3.4 in 1000 chance of having leaking in the aortic valve (aortic regurgitation) and there are reported cases of leaking in the tricuspid valve (tricuspid regurgitation), which seems to be due to damage to the valve from the VSD closure.
Rarely (<1% risk), the vsd closure device can dislodge and move (embolize) to somewhere else in body. this usually happens with small devices when edge of aorta isn't strong enough. but, most cases, be retrieved using a catheter.
There’s also a chance of getting an infection inside your heart (endocarditis) – between 0.3% to 0.9%. Additionally, high blood pressure in the arteries of the lungs (pulmonary hypertension) can develop post-operation, approximately in about 0.3 in 1000 patients. These are rare occurrences, but potentially serious which is why careful observation is required after the procedure.
What Else Should I Know About Catheter Management of Ventricular Septal Defect?
Advances in heart treatments have led to the development of a procedure called percutaneous transcatheter interventions for VSD. ‘VSD’ stands for Ventricular Septal Defect, which is a common heart defect where there’s a hole in the wall dividing the two lower chambers of the heart. This new procedure offers a treatment option for many people who, before this, could only manage their condition with medicines.
