Transcatheter Versus Surgical Closure of Ventricular Septal Defect: A Comparative Study
Condition: Heart Defects, Congenital
MeSH terms: Heart Septal Defects; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Congenital Abnormalities
Study type: Interventional

Summary: 
      The aim of this study is to compare Safety, efiicacy and clinical effects of surgical versus
      transcatheter closure of ventricular septal defect (VSD ).

      The outcome of interest is success rate, residual shunts, effect on tricuspid and aortic
      valves, need for blood transfusion, length of hospital and intensive care unit ( ICU ) stay,
      complications especially complete heart block, affection of kidney functions due to the
      procedure length caused by Cardiopulmonary bypass in case of surgical group or by the dye
      used in the group of transcatheter closure.
    

Detailed description: 
      Both of transcatheter and surgical closure of VSD is a well-established procedure. Despite
      the wide using of both procedures, there is a defect in the evidence comparing the short-term
      outcome and the value of both techniques. Our multicenter study aims to compare the immediate
      outcome of both procedures in Egypt.

        1. INTRODUCTION/ REVIEW with variable degrees of successes. Perimembranous VSDs have more
           intensiveLock et al in 1988 . Ventricular septal defects are the most common congenital
           heart diseases in children and are the second most common congenital abnormality in
           adults(1). nearly accounting for one-third of all cases. The extent of the opening may
           vary from the pin size to complete absence of the ventricular septum. There are 4 main
           types of VSD, the most common one of them is membranous type which accounts for almost
           80% of all VSDs (2). Most isolated muscular and perimembranous VSDs (pm VSDs) are small
           and close spontaneously. Large eccentric pmVSDs were recommended to be closed for fear
           of infective endocarditis, aortic regurgitation, and pulmonary hypertension(3). Surgical
           closure is still considered the gold standard management since being first reported in
           1955(4). However, transcatheter closure of some types of VSDs has been introduced into
           the clinical practice as an alternative to the surgical repair. Transcatheter closure of
           VSDs were initially made with the occluders of atrial septal defect (ASD) & patent
           ductus arteriosus (PDA) as reported by Lock in 1988 (5) with variable degrees of
           successes. Perimembranous VSD have more intensive demands on device design due to their
           nearness to the aortic valve. Hijazi et al. were first to report a successful closure of
           perimembranous defects with the occluder in six patients.(6) AMPLATZER muscular VSD
           occluder still the most common used device for transcatheter closure of muscular VSDs
           with generally accepted results.(7) However, The high cost of catheter closure, as well
           as device-related complications such as complete heart block (CHB), device embolization,
           aortic and tricuspid valves regurgitation, had limited its use (8) . nonetheless, the
           outcomes of using the transcatheter procedure to treat Perimembranous ( pm) VSD have
           been improved significantly in recent years because of improvement in device design and
           operator skills (9).

           Superiority of one procedure over the other is still an issue of debate. Consecutively,
           it is now possible to compare the outcome of both techniques as the data comparing the
           outcome of them are so limited.

        2. METHODOLOGY:

           Patients and Methods/ Subjects and Methods/ Material and Methods. Type of Study:
           Prospective purposed comparative study.

        3. Study setting:

           The study will be conducted at both of Academic institute of cardiac surgery and
           National Heart Institute.

           Study Period: One year. Start point: Once the protocol approved from the ethical
           committee.

           Study Population:

           The population of study is divided into two groups, Patients undergoing surgical VSD
           closure group(control group) & Patients undergoing catheter VSD closure group.

        4. Patient evaluation & selection:

           All patients will be evaluated by independent cardiologist.

        5. Sampling Method Patients who are suitable for transcatheter closure according to the
           Indian guidelines 2019 will be offered transcatheter closure firstly, other eligible
           cases for the study but not suitable for transcatheter closure or patients who have any
           troubles with transcatheter closure, will be treated surgically.

      Sample Size:

      72 patients divided into 36 patients in each group using pass 2 program for sample size
      calculation according to previous literature(12). setting power at 80%, α error at 0.05.

      6. Ethical Considerations:

      All the following will be applied:

        -  Informed consent will be taken.

        -  Patient information sheet will be given to the patients. - Confidentiality & Privacy.

        -  Privileged communication.

        -  Respect and responsibility.

           7. Study Procedures: An informed consent would be taken from the parents of the
           patients. All procedures would be performed under general anesthesia.

      Note: my role is only to observe and assist only.Each patient in both groups would be
      subjected to:

        -  Full history taking.

        -  General examination.

        -  Cardiac examination.

        -  Routine investigations which include 12 lead ECG, Laboratory investigations (CBC, PT,
           PTT, ESR, CRP, Urea, Creatinine, liver enzymes, bilirubin), Chest X-ray P/A view.

        -  Complete diagnostic transthoracic examination by 2D ECHO, doppler and color flow mapping
           with probe frequencies appropriate for each patient size to assess:

      I. Interatrial septum. II. Interventricular septal defects (number, size and site). III. Left
      Ventricle dimensions, volume and systolic function. IV. All cardiac valves morphology and
      flow. V. Right ventricle size &systolic function by TAPSE. VI. Estimated Right ventricular
      systolic pressure (RVSP ) using tricuspid regurgitation (TR) jet and/or estimated mean
      pulmonary artery pressure (PAP) using PR regurgitation jet.

      ▪ Surgical closure of VSD: Surgical closure would be done under general anesthesia,
      hypothermic cardiopulmonary bypass and cardioplegic arrest. Chest would be opened through
      standard median sternotomy (13). Surgical techniques would be determined according to the
      nature of every defect and includes direct closure, patch closure which involves. All
      patients will be transferred to the ICU for further follow up and management.

      ▪ Transcatheter closure of VSD: done for more detailed assessment of the defect size, to
      guide the procedure and for proper assessment after device positioning yet before its
      release. the use of autologous pericardium; however, polyethylene terephthalate (Dacron; C.R
      Bard, Haverhill, MA) and expanded polytetrafluoroethylene (Gore-Tex; W.L. Gore & Associates,
      Inc., AZ) may be occasionally used. These patches are held with continuous or interrupted
      sutures. Direct closure (without a patch may be done for the very small defects14. Most VSDs
      would be repaired through right atriotomy to avoid the undesirable effects of
      ventriculostomies(14). Under general anesthesia, patients will be fully heparinized (100
      IU/Kg) with follow up by activated clotting time. Intraoperative TEE will be relation to the
      surrounding structures especially the distance from the tricuspid and the aortic valves

      Left ventricular angiogram will be done in left anterior oblique (LAO ) 60 degree , cranial
      30 degree projection to define location and size of the defect. Accordingly, proper selection
      of the device size(15) . Only FDA approved devices would be used, after release of the device
      left ventricular angiography will assure proper device positioning, and transoesophageal (TEE
      ) or trans thoracic echocardiograph(TTE) will be used to assess nearby structures and nearby
      valvular flow.

      All the patients will recover from the general anesthesia, then transmitted to the ICU for
      follow up.

      The patients of each group will have all the routine labs repeated, 12 leads
      electrocardiogram (ECG), complete TTE and chest x-ray, all these data will be analyzed.
    

Intervention name(s): Ventricular septal defect closure surgery; Ventricular septal defect closure catheter
Intervention type(s): Procedure; Procedure
Intervention description(s): Ventricular septal defect closure surgery; Catheter closure of VSD
Other intervention name(s): patients undergoing surgical VSD closure; Patients undergoing VSD trans catheter
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The population of our intervention study is divided into two groups of participants receive different interventions.
group (A) Patients undergoing surgical VSD closure (control group) group (B) Patients undergoing transcatheter VSD closure.
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment