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Congenital Heart Disease

Feb 20, 10:00 AM

Dr. Bhavik Champaneri: VSD Device closure is best the strategy Dr. Amit Mishra: Surgical closure is preferable

[Music] pleasure being here good evening to all of you we have dr bhavik champaneri from the prestigious u.n mahita institute and talking about the case today of a 10 year old with the bst and his perspective on things dr bhavik yeah so can i share my slides good afternoon everyone [Music] yeah so is this slides visible hello yeah so good afternoon everyone uh i'm thankful to the committee of cardio for giving me this opportunity so the case which has been given to me is basically a 10 year old female who is having exercise cutting c fatigue season nyh class 2 she's having a great 4x6 systolic murmur and she's diagnosed to have a perimembranous vsd which is measuring around 4 mm in diameter and which is uh away from avota 6 mm in length she's having a mild pulmonary hydraulic hypertension and qp by qs calculated is somewhere around 2.1 is to 1 so looking at this data which has been provided there is no doubt that this patient requires some sort of intervention uh it can be either a transcatheter device closer or it can be surgical closer but being a pediatric cardiologist i always prefer uh trans catheter intervention because overall looking at the data it looks like a straightforward case for a device closer so my strategy would be to do transcatheter vsd device closure in this patient and my device selection would be six four eighty or two that's an employee duct uploader uh second my approach would be arterial because uh it's relatively easier you don't have to make ultraviolet loop and you can finish this device closer within i would say 15-20 minutes of time so uh so first of all uh i don't have doubt on capabilities of our sergeant dr mishra uh and i would say uh it's beyond a point it's proven that surgical vst closure is very safe procedure very effective and it can be done without any uh complication as well so my focus would be uh how i will be justifying my procedure would be on few advantages which i will focus uh over the surgical vsd closer and one more thing i would uh i have to confess that any uh cardiologist or any pediatric cardiologist who is doing intervention he becomes more and more confident and you become more aggressive if you have a surgical backup like amit misrasa so i have to uh give respect to surgeons as well because they increase our courage and they increase our aggression so coming to the uh case so what what what is what are the advantages of trans calculator vsc device further so first and uh foremost we will avoid sternotomy by doing transgender vsa device further we will avoid cardiopulmonary bypass by doing transcatheter device it will have a short icu and hospital state it will have less ico complication because the newest child is going to stay less in ic it will have a less psychological issues so i have actually focused more on psychological aspects of surgery having a scar on body rather than listing the demerits of surgery because anyway surgery is proven uh to be very effective so i would focus more on the psychological aspects uh of uh having a surgery versus trans cancer device closer and first is a sternotomy scar so actually once you use sternotomy scar is going to have with you for your lifetime and no one has given thought how uh that scar is going to affect his day-to-day life or various domains of life and this is the study uh uh where which have come across where they have studied the uh effect or significance of sonogram scar it was a questionnaire based study hundred patients were included in the study all were adults above 18 years of age 53 were male and 47 were female so on asking question nearly 60 percent felt that having a scar affected their life during adolescence period so 60 percent of patients told that adolescence they were very much conscious and they were it was affecting significantly to have a scar on their chest 60 percent fed their body has been disfigured by having external scars 50 percent of population feels that they want to consider this car so that again says source how mental uh mental trauma or i would say what is the psychological effect of having a scar on them attention or to the scar by other people nineteen percent felt that they have they are having a negative impact on or on attention to the scar with nearly sixty percent felt they are not feeling anything for that and actually twenty three percent had a positive effect they were feeling positive to have a scar on the chest there was no effect of uh having a scar on choice of their career success in life fancy sexual life etc coming to comp uh skydiving bypass complications there are like plenty of complication which has been described and various reasons for that but with over a period of time with newer strategies this complication has overall come down significantly and nowadays we don't see much of complication but i if i i would say majority of uh cardiologists cardiac surgeon in intensivist scenes are complications which is related to cardiovascular bypass and we've come across very frequently a cases where you have a renal dysfunction or liver dysfunction post cardiopulmonary bypass often it improves over a period of time but it accounts for some morbidity and increase your ico and hospital state coming to psychological impact this is an important paper publishing cardiology in the young where they have actually studied what is the psychological impact of having a surgery and what is psychological impact of having a device program and in this study they assess and compare the behavioral and emotional outcomes after surgery or transgender closure of bsd device actually it was again a checklist was given to parents about child's behavior and another 28 item question and was also given to us as parents psychological stress which we are undergoing after surgery or after device program 29 patients were in a surgical group and 35 patients were in a device group the results was behavioral problems were greater in both the groups when it was compared to normative data or normal population but when you compare between the surgical and device group the depression and somatic complaints are higher in patients who have undergone surgery and risk factors which were found to be significant by young age and repair to have a sternal scar heteroventricular block maternal anxiety etc so uh this is again it's it focuses that psychological trauma after surgery is a relatively on a higher side as compared to trans categorical device uh what is data on comparing the vse device versus vsd certificate closure and this is a randomized control trial which have come across which was published in jack in 2014 where they have actually compared uh in a randomized manner very concrete membranes vst device versus bsd surgery actually they after analyzing 465 patients totally 101 patients were analyzed who were having uh translated a device closer and 99 patients underwent surgical closure and if you look at the chart both the groups were actually age matched great men so there was no discrepancy actually manifestations were also more or less similar ecocardiographic data and invasive data were also not significantly different they were more or less similar so they wanted to have two groups which are more or less in a similar aspect but if you look at the procedural details blood transmission requirement was significantly higher in patients who underwent surgical group procedural duration if we look which was very high in patients who have undergone surgical group hospital and icing stay obviously was higher in patients with a surgical group most important thing was time to return to normal activities so this is very important in uh current scenario uh that time to return to normal activities was significantly higher that was somewhere around 18 days or in a surgical group while patients with device closer uh were normal after three to four days of procedure when we are looking at major adverse events uh there is no difference between surgery and transgender they found that surgical group was having a significantly minor increased uh risk of minor leaders events but they included actually blood transfusion as in minor remain so if we remove this blood transition there was again no not much of difference between surgical and transcatheter group you can see here arrhythmias were also more or less similar in both the groups uh this is another uh study which i've come across it's a systematic review published in cat cbi in 2015 uh total 3 300 patients uh were enrolled in the study device patients were around 1300 certification for around 1800 success threat when they it was compared between surgery and device group it was more or less similar with the p value of 0.67 major complication they included death reoperation uh permanent pacemaker implantation for heart lock and there was no significant difference between these two groups the residual stunt again which was significant was again not uh it was similar in both the groups with p value of point four one average regurgitation practically education number also found to have similar in both the groups need for blood transmission and hospital stay was higher in patients with surgical growth uh what is indian data [Music] so i have taken four case series which are the largest case series of published from india the first one is from u.n meta having a uh a case series of 430 patients dr nagasura is from hyderabad from bangalore from mumbai and if you see the number it's a quite a good number uh published before by 2012 uh and uh the majority of patients undergoing vsa device was very important as the device program and if you look at the success rate it is very high more than 98 majority of series and if you look at the incidence of hard block post uh procedure uh it comes to less than one person i would say around one person and the risk of embolization was somewhere around one person uh on follow-up they didn't have any patient with complete heart block uh with nearly three to four years of follow-up and residual strength was also not very significant in uh follow-up uh so i would i would like to have a case example similar to the case provided to me it's an eight-year-old female she's having five to six mm of periwinkliness vst an iot cream of seven mm this is an eco picture you can see llv is dilated this is the perimeter of this vsd measuring 6 mm and iot grip is around 7 mm station has been taken into cath lab see underwent integrated venus approach device closure uh using 10 8 area one that's an employee occluded one uh post procedure ngo suggesting no significant residual flow this is a post procedure eco picture showing mild or trigger tr and device in good position with no residual flow similar 14 year old female she's also diagnosed with moderate fairy membranos vsd but she's having a secret fighter speed regulation because of indirect airport uh actually patient was referred for surgery on evaluation we found to have moderate perimembranous vsd and significant tr as you can see here uh patient was taken into catholic cnn device closer with a 10 8 801 device and dr has come down significantly with eventual uh tr remaining mild device in good position no iot regurgitation no residual flow across device so this i wanted to highlight another case so it's not always certain who is spelling out cardiologists cardiologists are also they are bailing out surgeons so this is another case 12 year old male patient who has underwent intra cardiac repair for tetragonal and is coming back after uh after six to eight months with severe pulmonary active hypertension right ventricular dysfunction severe and residual vsd of around nine and device patient did well and he is two years post procedure follow-up is doing that so coming to the conclusion if we are selecting cases very carefully intervention is superior to surgery if we look at in terms of cosmetic results psychological outcome financial result as well hospitalization blood transfusion requirement transgender intervention is non-inferior to surgery in terms of major and minor complications so i would like my child to have a normal chest without scar as compared to a scar chase thank you and i will look forward to dr amit misra for his uh explanation towards surgery thank you thank you thank you dr bhavit very enlightening let's now look at what dr amit mishra has to say he's a senior pediatric cardiac surgeon also from unmet dr mishra thank you my slides are visible now yes sir it's visible you can go inside okay thank you thank you so i think the details of the patients and most of the advantages of devices are already covered by dr marvik and he's already covered 50 of my things debate should be there as we get to see lot of variety of the cases variety of the vsds and all that there is always some controversy whether it can be done better in a device or it can be done surgically being a certain i always think that it can be it's a simple thing can be done on the surgically but no doubt no doubt surgery is not not free from any side effects or complications because surgery surgery a lot of people are involved in studies are involved heart lung machine is involved pre-operative post operative ionotrope icy care blood all these things are involved so if if a good job can be done in by intervention cardiologist we have no harm we absolutely know how like in this patient 10 year girl 4 millimeter vst 2 is to 1 shunt no symbiotic membrane no right ventricular outflow attack obstruction i i i think that in a 10 years old girl with a restrictive efd for so many years there must be some fibrosis in right ventricular possibility of same there is a possibility that right coronary cusp is prolapsing and maybe that this is the tricuspid valve uh is obstructing the vsd that is possible but having said that the case is different what we are discussing now and honest honestly speaking we hardly see such case we hardly see such a clean case for vfc closer because the cardiologists are gatekeeper they will finish and you don't even know that certain patients are admitted or gone home unless there is some problem then only we are in picture otherwise for such cases we are not being called offs now catheter management ado and this is the first time i was going through radio 1 2 3 and avp2 they are not yet i recently saw in the article i don't remember the year which it is published but they are not yet usfda approved and device closure is recommended as whenever you have a two to three millimeter rim just beyond below the aortic analysis now and device has its own complications there is a higher incidence of arrhythmia we don't see so many arrhythmias in a clean vsd closure like this there's a very high incidence of complete heart block if you go by a surgery there's less than two percent especially if the experts are there then less than one percent incidence of heart block right bundle left bundle branch block and there is a very high almost three point two percent incidence of the permanent pacemaker implantation other there can be a traumatic injury to the tricuspid wall aortic valve ar is there air is most of the time it is progresses once the air is developed or you enjoy the aortic valve there's a fair chances that ar is going to progress over a period of time then we also get a residual vsb especially if it is at the junction with the tricuspid well there is a possibility of one millimeter vsc this obviously can be there but most of the time it should heal so devices also have an incidence of the five to six percent uh incidence of the um residual bst then there is a possible possibility of uh hydrogenic embolization it may go to any place once it is you left the device it may go into aorta into pulmonary artery or into branch pulmonary arteries anyway and cost is of course a major factor devices are are expensive one more thing which i was going through the article there is no long term study which has shown what is the status of left ventricular outflow tract especially after five years or ten years of device because these are a nutella mesh there's a endothelialization and that that endothelial portion is going to come in the left ventricular output track so how it is going to behave over a period of time that we don't know when we put a patch it is on the rv side only and it is just thin less than one millimeter diameter of the patch 0.4 millimeter so the left ventricular outflow tract is not a question in obviously surgical clothing so this i am not sure how the in the coming time this left ventricular output issue will be there and how the patient will be behaving in the coming time especially the post device closer because you are close to two valves and the left ventricular output act then this is one of the article we have published few years back i still remember that patient he was a small eight to ten years old child from the rajasthan and he had vsd ps in fact there was a ps also so that is the balloon dilation of the pulmonary stenosis and did the device closure of the perimenopause incidentally this device is slipped into the arch but the cardiologist was so aggressive that he has pulled back the device and put it again into the perimeter and after four years four hours i gotta call the devices embolized back into the arch so in emergency i have to go back and i have to remove this device it was just in front of the innominate artery and you can see the device is quite large it can obstruct both the nominate as well as the keratin rt can have major disasters so devices are not free from the complication this is what i believe i've done few more cases but this i could this is we have published so i could immediately retrieve all these things so this is we will retrieve the device and see last device in eight year old child from the ascending order then i would like to conclude here that please do it devices we um we all are working basically for the patients whenever it is safe please do it and the best part you people have you always have a surgeon on your phone call so if you if you are any mess we are there we are there you know but you will not come and rescue that yeah of course you have shown the examples that you are coil embolizing residual yes that's a joint effort no doubt but you know if some if there is a surgical bleeding there's nobody you are the only one or maybe glue that's all these are the two things which you are going to have so and i personally believe we can close this kind of vsd and we can retrieve also if it is required from here we are well-versed with the i told you if the surgeon is experienced there's less than one percent chances i believe i don't know exactly what is my result but less than one percent chances of heart blocking and we can avoid injury to the aortic valve triggers especially if the surgeon is experienced there's least chances of tricuspid valve injury or aortic valve injury or if they're tiny pfo that will also be closed if there are small pda that is also will be taken so all these things are complement when you are doing this thank you thank you very much i think i am in time any questions thank you is is dr tushar there my co-chairs or the moderator so just one question you told that it's not a usfp approved but have lgbt unless it's a very much oversized device usually on falloff also we haven't come across a single case where lvot isn't concerned but still long term it's a long term there are there are articles which says that there is an italian disk lying on the led side of the vsd yes yes it lies so thin thin subiotic membrane gives you the gradient if this fibrous tissue keep increasing there is a possibility i am just saying that this is there is a possibility that these things can can occur in the future i am not saying this will happen but there is a possibility you may see these things in the coming future and you are close to two valves striker speed aortic conduction all this all the area around the vsd are surrounded with the problem but still you go and put it we don't mind in muscularis and all that you please do it and as i said earlier please do it we are there don't worry in the last case which i posted i think it's a great discussion on this simple case it's good to have this such simple case for surgeon but i think cardiology should do this case very nicely i have few points to say as a surgeon being a surgeon i would like to say that many times uh straightforward vsts dr mishra has already mentioned they have suffered they have non-obstructive servatic membrane which you might have missed on the echo you have missed many a times such patients going into gasolinization which is not producing even ps they have bundles in the rvot they have additional pda and most of the time such simple case but there are a lot of cord across in there and your device is hanging in between and you are damaging the tractor speed ones so we have retrieved such cases uh such devices on such simpler cases uh coming to the point of scar 10 year old can be done such simple vst can be done through minimally invasive vst closure truth or economy is it possible that is also a possibility so uh given a point if it is a really straightforward case no coda crossing the cross device is best but yes long term results are required for the uh knowing the healthy obstruction because our patch even causes uh some amount of uh fibrosis on the lb side and leads to psoriatic membrane later on and produces algae friction and when this such big disc is prolapsing into the lbot it is going to produce a duty obstruction in future probably it may come up after few more years and then we'll see retriving device and putting a patch again it is horrible it is horrible it's going to be a worry but it will be a nightmare for us it is just not possible then it will cause damage to the iot call as well as it will cause conduction damage you will not get such cases we are just predicting the possibility unless the ridiculous problems will come we can't comment anything yes okay that's a nice discussion thank you both of you sir nice discussion and uh very nice psychological aspect uh ring on by the ravicha paneri uh we do not you know uh very much concerned about those things we are very much into the intervention and strategy but the psychological aspect is very important and as dr mishra said like uh being very aggressive uh on every every intervention and every year to do device closure like in this case uh like there is six millimeter of margin is there but sometimes interventional cardiologists become so aggressive because of availability of the surgeon that there are chances of ar and when we do the device close-up from the aortic valve so because of the cable and everything we cannot judge properly uh before releasing the theme so any degree of ar it will increase in the future and all so tricuspid value involvement and other associated lesion always go for the surgery but otherwise this is i mean straight forward pretty straight straight for our case for the device closer otherwise uh one need to you know properly evaluate the case and then accordingly this night very nice my question to all of you uh ten-year-old presenting 2.2 i think dr mishra pointed it out to pqs quantification would it matter whether it's echocardiographic invasive again uh european guidelines are more strict for perry membranous because of the chb and the rhythm disturbances and the subsequent elvis function for devices american guidelines though they are not fda approved for the devices per se as dr mishra pointed out but are more liberal in terms of doing uh devices so comments from all the chairs and i think we have yeah sorry sorry man continue now please go ahead dr bhavik i think we have enough data from indian cities as well so we have actually 2012 people in 2014 problem is in india we don't publish yeah the public's guideline what i'm telling you publishing yeah the guidelines still don't call perry members into class one as far as i know i mean you can clarify it's a class two-way indication for perimeter yes but still that guideline will change over a period of experience yeah obviously i agree so um if i may add it's very clear that the way for a pda it's standard of care that transcatheter is one it's not true for a perimember this vsd does not so i don't know if dr kamal had me on as a chair purposefully i'm a non-interventional pediatric cardiologist and perhaps i have a unique perspective because of that i believe that the most important aspect here is patient selection number one i feel all patients uh pre-intervention or pre-surgery need to have the feedback from both the cardiologist and the surgeon the surgeon should know that certain such patient is going to the cath lab and i think i think that's where the whole thing lies i think uh once it's decided it's a trans catheter uh procedure then everything should be straightforward because your whole strategy should be you know sorted out i would also say that follow-up is vital whether you do it surgically or you do it in the cath lab follow up one year five years ten years later is vital and um i i think as long as we remember that you know whether a surgeon or a cardiologist we are working for the patient i think everything falls in place thank you thank you all both of you

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