Original title: Transcatheter versus Surgical Closure of Perimembranous Ventricular Septal Defects in Children: A Randomized Controlled Trial. Reference: Jian Yang et al. J Am Coll Cardiol. 2014; Epub ahead of print.
The ventricular septal defect (VSD) is the most common congenital heart disease, and perimembranous being the most common variant. In countries like USA surgery is considered the treatment of choice for this variant of VSD since the initial studies on percutaneous closure had a high chance (2.9 to 5.7 %) of complete atrioventricular block. However in developing countries like China and India, percutaneous closure has shown low mortality and morbidity using specially modified nitinol devices for perimembranous variant.
Between January 2009 and July 2010, 465 patients aged 3 to 12 years diagnosed with perimembranous VSD were evaluated clinically and with transthoracic echocardiogram in 3 high-volume centers of China, finally leaving 229 who met the criteria for inclusion and exclusion be randomized to surgery (n = 115) and percutaneous closure (n = 114). Patients randomized to percutaneous closure received the device Shanghai pmVSD occluder (Lepu Medical Technology Co, Ltd, Beijing, China), designed especially for perimembranous VSD. In the case of surgery,direct suture or Dacron or pericardial patch was used, depending on the size.
Mean age was 5.8 ± 2.4 years in the surgical group versus 5.5 ± 2.6 in the percutaneous group (p = 0.398). There were no differences in other baseline characteristics including the size of the defect.
No deaths, strokes or other major complications were observed in-hospital. There were 32 (32.3 %) minor complications in the surgical group versus 7 (6.9 %) in the percutaneous group (p < 0.001). After two years, no deaths were reported, neurological deficits, thrombus embolism, endocarditis, or complete atrioventricular blocks. The end diastolic volume assessed by echocardiography (Z score) decreased significantly in both groups.
Conclusion
Both surgical and percutaneous closures were effective and showed excellent mid-term results for treating perimembranous ventricular septal defects. In this paper, percutaneous closure had fewer incidences of myocardial injury, transfusion requirements, hospital stay, economic costs, and recovery time.
Editorial comment
Infundibular and tubular types of Perimembranous VSD were technically more simple to treat percutaneously than the aneurysmal type, if so far possible, may need more care.
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