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Eur J Cardiothorac Surg 2004;26:1044-1046
© 2004 Elsevier Science NL

How-to-do-it

Use of muscular VSD Amplatzer occluder for closing right ventricular free wall perforation after hybrid procedure

Magorzata Pawelec-Wojtalik^a,*, Pawe Antosik^c, Grzegorz Wsiatycz^d, Micha Wojtalik^b

^a Department of Angiography and Haemodynamics, University of Medical Sciences in Pozna, Pozna, Poland
^b Department of Pediatric Cardiac Surgery, University of Medical Sciences in Pozna, Poland
^c Veterinary Department, University of Agriculture in Pozna, Poland
^d Veterinary Clinic in Pozna, Poland

Received 28 June 2004; received in revised form 15 August 2004; accepted 18 August 2004.

^* Corresponding author. Ul.Szpitalna 27/33 60-572, Poznan, Poland. Tel.: +48 603 681182; fax: +48 61 8669130. (E-mail: mpwojt{at}poczta.onet.pl).

	Abstract

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 
In some patients, so cold hybrid cardiologic procedures are performed whereas a heart is exposed surgically to puncture directly the heart cavity. After performing the interventional procedure, the opening in ventricular wall is closed surgically. We present our initial experience with closing the right ventricular (RV) cavity opening with the muscular ventricular septal defect Amplatzer occluder (A-MVSDO). In four sheep, heart was exposed surgically and punctured under direct vision by needle and guide wire, 14F and 26F sheath were introduced into right ventricle and the A-MVSDO was introduced causing closure of the RV opening. In all four cases, the occluder was successfully placed closing the opening in RV. No major bleeding after occlusion was observed. Following complications were observed: pneumothorax in two animals, rhythm disturbances and thrombus suspected in one. A-MVSDO occluder seems to be a useful device to close RV opening after hybrid interventional cardiologic procedure.

	1. Introduction

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 
Growing experience in interventional cardiology leads to use of large diameter of vascular equipment aiming in implantation of occluders or stented valves [1–5]. Low weight and small diameter of access vessels and sometimes thrombosis after previous procedures limit the use of these methods in some patients [6].

In some instances the so cold hybrid procedures are performed whereas a heart is exposed surgically to puncture directly the heart cavity. After performing the interventional procedure the opening in ventricular wall is closed surgically [1].

	2. Aim of the study

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 
The aim of the study was to check if a muscular VSD Amplatzer occluder (A-MVSDO) can be used for closure of the right ventricular (RV) free wall opening after hybrid interventional cardiology procedure.

	3. Material and methods

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 
The experiment was performed on four Fryza–Merynos sheep weighting 45–48kg. Animals after introduction by intramuscular Ketamine, were intubated and inhalated with Halothane to achieve general anesthesia. A catheter was placed in jugular vein to keep access for medication and blood sampling. Before procedure a 50U/kg dose of heparin was administrated intravenously. Activating clotting time (ACT) was checked before and after by the use of DRG apparatus. The aim was to keep ACT between 180 and 200s.

Four extremity ECG leads were placed to record heart rhythm disturbances.

The heart was exposed through right IV intercostals space lateral thoracotomy. The right ventricular wall was punctured under direct vision well away from major coronary vessels by needle and guide wire, 14F and 26F sheath were introduced into the right ventricle. The location of sheath was checked by transthoracic echocardiography through left parasternal view using an ECHOSON apparatus with 3, 5MHz sector transducer. After the proper placement of the sheath within right ventricular cavity was confirmed, the A-MVSDO (12mm diameter in three cases and 14mm in one case) was introduced. We used a typical Amplatzer introduction set for this purpose. First, distal disc was opened in RV and after withdrawal the external disc outside the heart causing closure of the RV opening (Fig. 1). Opening the external disc could be seen directly (Fig. 2). At that moment, the eventual bleeding through and around occluder was observed. As soon as the position of A-MVSDO was confirmed, the leader was detached and the chest closed.

View larger version (149K): [in this window] [in a new window]   Fig. 1. Transthoracic echocardiogram showing the A-MVSDO completely opened on the RV wall.

View larger version (170K): [in this window] [in a new window]   Fig. 2. The A-MVSDO completely opened on the RV wall—intraoperative view.

Second animal was terminated 8 weeks after and late specimen was obtained. This sheep received intravenously heparin 50U/kg b.w. every 6h continued by fraxiparine once a day for 7 days after procedure. Remaining two animals were sacrificed 8h after procedure without postmortem examination.

	4. Results

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 
In all four cases the occluder was successfully placed closing the opening in RV. No major bleeding after occlusion was observed. One sheep died due to pneumothorax 2h after procedure. The diagnosis has been confirmed by chest X-ray. Other one had pneumothorax treated by short time pleural drainage.

In two cases heart rhythm disturbances were observed—in one case bradycardia treated by adrenaline infusion and in second ventricular tachycardia treated by cardioversion.

In one case, the thrombus formation in right atrium was suspected. The control revealed 54s. The extra dose of Heparin was administrated. No further increase of thrombus was observed thereafter.

	5. Discussion

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 
During this study we confirmed that A-MVSDO can be used for closure of the RV free wall opening after penetration with large diameter sheath used for interventional cardiologic procedures. The bleeding through and around the occluder was unimportant. Possibly this was due to low pressures in RV as well as to sufficient sealing properties of the device.

Pneumothorax was observed in two animals with one lethal course. This complication can be explained as our technical error—not leaving chest drainage as a routine procedure during closing thoracotomy. Small mechanical injury of the lung by the occluder moving with heart rhythm cannot be excluded.

Heart rhythm disturbances were noted during experiment in two animals. The cause was mechanic irritation of myocardium by manipulation with the needle and sheath. Positive observation was that occluder did not cause any heart rhythm disturbances in any case after implantation.

In one sheep, thrombotic complication was suspected. We do not think that this was due to occluder since the location of thrombus was quite far away from device. Still it is possible that a device will cause thrombus formation. Therefore, we accept antithrombotic regime recommended by AGA Medical Corporation—producer of Amplatzer occluders.

	6. Conclusion

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 
A-MVSDO occluder can be used to close RV opening after hybrid interventional cardiologic procedure.

	Footnotes

 
The Editorial on pp. 873–4 of this issue should be read in conjunction with this article.

	References

Top Abstract 1. Introduction 2. Aim of the... 3. Material and methods 4. Results 5. Discussion 6. Conclusion References

 

1. Bacha EA, Cao Q, Starr JP, Waight D, Ebeid MR, Hijazi ZM. Perventricular device closure of muscular ventricular septal defects on the beating heart; technique and results. J Thorac Cardiovasc Surg 2003;126:1718-1723.[Abstract/Free Full Text]
2. Bonhoeffer P, Budjemline Y, Saliba Z, Hausse AO, Aggoun Y, Bonnet D, Sidi D, Kachaner J. Transcatheter implantation of a bovine valve in pulmonary position: a lamb study. Circulation 2000;102:813-816.[Abstract/Free Full Text]
3. Criber A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, Derumeaux G, Anselme F, Laborde F, Leon MB. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis. First human case description. Circulation 2002;106:3006-3008.[Abstract/Free Full Text]
4. Boudjemline Y, Agnoletti G, Bonnet D, Sidi D, Bonhoeffer P. Percutaneous pulmonary valve replacement in a large right ventricular outflow tract. An experimental study. J Am Coll Cardiol 2004;43:1082-1087.[Abstract/Free Full Text]
5. Huber CH, Tozzi P, Corno AF, Marty B, Ruchart P, Gersbach P, Nasratulla M, von Segesser LK. Do valved stents compromise coronary flow?. Eur J Cardiothorac Surg 2004;25:754-759.[Abstract/Free Full Text]
6. Journeycake JM, Buchanan GR. Thrombotic complications of central venous catheters. Curr Opin Hematol 2003;10:369-374.[CrossRef][Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michal Wojtalik Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pawelec-Wojtalik, M. Articles by Wojtalik, M. Search for Related Content PubMed PubMed Citation Articles by Pawelec-Wojtalik, M. Articles by Wojtalik, M. Related Collections Cardiac - other