Transcatheter closure of ventricular septal defects by exclusive transvenous antegrade cannulation from the right ventricle
Authors: Sagar Pramod , Thejaswi Puthiyedath , Garg Ishita , Sivakumar Kothandam 
Published: May 2024

Background

Transcatheter closure(TCC) of perimembranous ventricular septal defects(PM-VSD) and intraconal defects routinely involves either arteriovenous loop formation or direct retrograde device deployment from its left ventricular(LV) end. An arterial access is always taken for a left ventriculogram. Direct antegrade cannulation of the defect from the right ventricle for TCC avoids complications associated with femoral arterial access and arteriovenous loop formation.

Methods

Feasibility of elective antegrade cannulation for TCC of PM-VSD, intraconal VSD and postoperative residual VSD was retrospectively studied over five years from 2019-2023. Echocardiographic VSD measurements guided the device selection rather than left ventriculographic measurements. Predictors for successful antegrade cannulation and transvenous device deployment were analyzed.

Results

Antegrade cannulation was electively attempted in 116/163(71%) TCC VSD closure procedures. The proportion of cases where this antegrade cannulation was electively employed progressively increased from 26% of interventions performed in 2019 to 93% in 2023. The median age of the study cohort that included 24 infants was 55 months (range 1-636 months) and the indexed VSD size was 9.2 mm/m2(range 1.7-43.3 mm/m2). Two-thirds of patients had varying degrees of pulmonary arterial hypertension. Antegrade cannulation was successful in 97(83.6%) patients. In the remaining 19 patients, retrograde cannulation from LV aided TCC. There were no deaths or need for pacemaker implantation. Overall procedural success of TCC in this cohort was 99.1%.Device embolization with tricuspid chordal tear led to procedural failure in one patient. Four other device embolizations were managed successfully by transcatheter retrieval and closure with an upsized device. Young age, small body size, large VSD size were significantly associated with successful antegrade cannulation.

Conclusions

Antegrade cannulation and TCC was feasible in majority of the procedures, especially in small patients and large defects. This strategy simplified the procedure without arterial access and might replace the routine retrograde device delivery and AV loop formation.

Abstract Figure

Graphical abstract

An exclusive transvenous antegrade defect cannulation from the right ventricle would avoid complications due to arterial access and arteriovenous railroad formation, simplify procedure and allow assessment of aortic valve before device release.

What is already known

Transcatheter closure of ventricular septal defects around the membranous septum is increasingly performed using soft occluder devices with results comparable to surgery.

Conventional approach involves a retrograde trans-arterial cannulation of the defect or arteriovenous loop formation.

What this study adds

Transvenous antegrade cannulation and device deployment is an alternative attractive technique.

As this avoids arterial access, additional hardware needed for arteriovenous loop formation and allows intraprocedural monitoring of aortic valve, this might replace the conventional techniques in future.