0931 Perventricular vs surgical closure of ventricular septal defects (VSDs)

VSD is the most common form of congenital heart disease (~20% of all congenital cardiac abnormalities). Surgery has long been regarded as the gold standard for treatment – in experienced hands and when isolated (i.e. the sole defect), repair is not regarded as particularly complex and morbidity and mortality are low. However there are issues such as the need for cardiac bypass, length of hospital stay, post-operative myocardial dysfunction, sternotomy and scarring, all of which come into consideration when a less-invasive option becomes available. Such an option, the Amplatzer occluder was introduced 10 years ago and further developed over the next few years. Several studies have been published and provided results from centres that adopted the new procedure. In general the outcomes have been good although most authors conclude with the comment that greater experience and long-term follow-up are required. A recently-published large, single-centre, retrospective study of 2178 patients would seem to be adequate to answer at least some of the questions. A group from Xian in China reviewed data for the years 2004-7. Subjects selected for surgery excluded infants (≥2.5 years or weight >11kg) and had isolated VSDs with left-to-right shunts, perimembranous VSD, outlet muscular defect or muscular defect of 3-12mm. Percutaneous closure was performed in 852 and surgery in 1326. Patients were not randomized i.e. perventricular closure was the preferred procedure where size and location of the defect were more suited to occlusion. In terms of immediate outcome the non-invasive procedure appeared to be the more successful with 6.4% of the surgery group experiencing complications vs 0.6% of the perventricular group. Complications included post-operative cardiac insufficiency, haemolysis, infection, pericardial effusion and pneumo- or hydrothorax. These were all regarded as minor complications; as for major complications, rates of severe arrhythmia, residual shunt, re-operation and valvular insufficiency were similar. However as with other studies, there is a risk of damage to the conducting system (bundle branch block) as a result of the perventricular procedure (in ~2% of cases), with long-term pacing required in some. A significant shortcoming of the Chinese study is its failure to report adequately on the subjects who were lost to follow up. Duration of follow up was at least one year but complete data were only available for 662 of the 852 ‘study’ patients and for 954 of the 1326 ‘controls.’

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