Complete Left Bundle‐Branch Block After Transcatheter Closure of Perimembranous Ventricular Septal Defect Using Amplatzer Duct Occluder II
2022; Wiley; Volume: 11; Issue: 7 Linguagem: Inglês
10.1161/jaha.121.022651
ISSN2047-9980
AutoresChangqing Tang, Shuran Shao, Kaiyu Zhou, Yimin Hua, Chunyan Luo, Chuan Wang,
Tópico(s)Cardiac Valve Diseases and Treatments
ResumoHomeJournal of the American Heart AssociationVol. 11, No. 7Complete Left Bundle‐Branch Block After Transcatheter Closure of Perimembranous Ventricular Septal Defect Using Amplatzer Duct Occluder II Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessLetterPDF/EPUBComplete Left Bundle‐Branch Block After Transcatheter Closure of Perimembranous Ventricular Septal Defect Using Amplatzer Duct Occluder II Changqing Tang, MD, Shuran Shao, MD, Kaiyu Zhou, MD, Yimin Hua, MD, Chunyan Luo, MD and Chuan Wang, MD Changqing TangChangqing Tang Department of Pediatric Cardiology, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China The Cardiac Development and Early Intervention Unit, , West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China Department of Cardiology, , Children's Hospital of Soochow University, , Suzhou, , China , Shuran ShaoShuran Shao Department of Pediatric Cardiology, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China The Cardiac Development and Early Intervention Unit, , West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China , Kaiyu ZhouKaiyu Zhou Department of Pediatric Cardiology, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China The Cardiac Development and Early Intervention Unit, , West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), , Ministry of Education, , Chengdu, , Sichuan, , China Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China , Yimin HuaYimin Hua Department of Pediatric Cardiology, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China The Cardiac Development and Early Intervention Unit, , West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), , Ministry of Education, , Chengdu, , Sichuan, , China Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China , Chunyan LuoChunyan Luo Huaxi Magnetic Resonance Research Center, , Department of Radiology, , West China Hospital, Sichuan University, , Chengdu, , China and Chuan WangChuan Wang * Correspondence to: Chuan Wang, MD, Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan 610041, China. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0001-5165-8273 Department of Pediatric Cardiology, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China The Cardiac Development and Early Intervention Unit, , West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), , Ministry of Education, , Chengdu, , Sichuan, , China Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, , West China Second University Hospital, Sichuan University, , Chengdu, , Sichuan, , China Originally published30 Mar 2022https://doi.org/10.1161/JAHA.121.022651Journal of the American Heart Association. 2022;11:e022651This article is commented on by the following:What Is Blocking Transcatheter Ventricular Septal Defect Closure?Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 30, 2022: Ahead of Print March 30, 2022: Ahead of Print Amplatzer duct occluder II (ADO‐II) is claimed to be safe and effective for transcatheter closure of perimembranous ventricular septal defect (PmVSD) with low incidence of postprocedure arrhythmias, particularly complete atrioventricular block and complete left bundle‐branch block (CLBBB).1 However, a recent study has reported 2 cases of complete atrioventricular block following transcatheter closure of PmVSD using ADO‐II.2 Data on CLBBB after device closure of PmVSD with ADO‐II were lacking. The incidence, risk factors, and follow‐up outcomes of CLBBB after device closure of PmVSD using ADO‐II might be completely different from that we have previously reported for symmetrical double‐disk device3 because ADO‐II is only suitable for small size of PmVSD. Therefore, the present study was performed to address these issues in children.The data that support the findings of this study are available from the corresponding author on reasonable request. This study was approved by the University Ethics Committee on Human Subjects at Sichuan University (No.2015[010]), and the written informed consent was provided by all patients' guardians. A total of 276 children undergoing successful transcatheter closure of PmVSD using ADO‐II (Abbott Medical, MN) between January 2016 and April 2020 in our center were retrospectively reviewed. The PmVSDs were closed because of increased left ventricular size (defined as left ventricular end‐diastolic diameter [LVEDD] Z‐score>2; n=51), recurrent lower respiratory tract infection (n=28), pulmonary arterial hypertension (n=12), growth retardation (n=13), cardiac dysfunction (n=4), and patient preference or social pressures (n=136). The mean, 25th, 75th, and 95th percentiles of LVEDD Z‐score were 0.31, −0.76, 1.92, and 2.95, respectively. Z‐score of LVEDD>3 was observed in 10 children. The process of transcatheter closure procedure was similar as previous study.3 With a follow‐up duration of 1 to 48 months, 32 patients were excluded because of incomplete follow‐up data, with a follow‐up rate of 88.4% (244/276). Of the 244 children included, 87 (35.66%) developed postprocedure arrhythmias, including CLBBB in 8 (3.28%), incomplete right bundle‐brunch block in 27 (11.07%), complete right bundle‐branch block in 8 (3.28%), left anterior hemiblock in 5 (2.05%), left anterior hemiblock and incomplete right bundle‐brunch block in 2 (0.82%), junctional escape rhythm in 14 (5.74%), junctional escape rhythm and incomplete right bundle‐brunch block in 1 (0.41%), junctional escape rhythm and left anterior hemiblock in 1 (0.41%), junctional escape rhythm and ventricular premature beats in 1 (0.41%), ventricular escape rhythm in 2 (0.82%), escape rhythm and conduction block in 1 (0.41%), first‐degree AVB in 2 (0.82%), second‐degree AVB in 1 (0.41%), and other impulse formation disorders in 14 (5.74%). Most of arrhythmias were transient, and persistent arrhythmias remained in 15 patients (6.15%). The mean±SD, median, and 95th percentile for QRS duration before the procedure were 80.68±9.20, 80.00, and 96.00 milliseconds, respectively. The corresponding values on latest follow‐up were 80.26±9.93, 80.00, and 95.95 milliseconds, respectively. Patients without any type of new‐onset arrhythmias postprocedure (n=157) were recruited as control group. Risk factors for postprocedure CLBBB were determined.Among the 8 patients with postprocedural CLBBB, early‐onset CLBBB was observed in 6 cases (4 cases developed at 1 day and 2 cases developed at 5 days after procedure). After intravenous dexamethasone (1 mg/kg daily) or oral prednisone (1–2 mg/kg daily) treatment for 2 to 5 days and tapered gradually, 4 of 6 patients had restored sinus rhythm within 5 days. The residual 2 cases regressed to normal rhythm at ≥1 month and at 9 months postprocedure, respectively. Late‐onset CLBBBs were noticed in 2 cases (1 case at ≥6 months and another at ≥19 months postprocedure). Both experienced persistent CLBBB but were asymptomatic during follow‐up. However, left ventricular enlargement, systolic dyssynchrony, and decreased systolic strain (GE Medical System, Horten, Norway) were observed in both patients (case 1, aged ≥6 years: LVEDD, 42 mm; global longitudinal systolic strain, 9.8%; global circumferential strain, 16.9%; case 2, aged 4 years: LVEDD, 40 mm; global longitudinal systolic strain, 10.3%; global circumferential strain, 8.3%). Only the operation time was identified as a risk factor for occurrence of postprocedure CLBBB (P<0.001) (Table).With the largest sample size, we first reported the midterm follow‐up outcomes of CLBBB after transcatheter closure of PmVSD using ADO‐II in children. Several novel findings were observed: (1) It was different from previous studies3 in that the overall incidence of postprocedure arrhythmias was not low (35.66%), which was even higher than that found in symmetrical double‐disk device (25.64%). Fortunately, most of them only exhibited as a short, transient phenomenon and there was no occurrence of complete or high‐degree AVB. (2) CLBBB could occur after transcatheter closure of PmVSD using ADO‐II despite the fact that it was uncommon (3.28%). The outcome was satisfactory because most of them restored normal conduction. Close follow‐up, however, needs to be applied because late‐onset CLBBB was observed. (3) Persistent CLBBB could lead to left ventricular systolic dyssynchrony and dysfunction. (4) Unlike our previous study3 in which an oversized occluder was a risk factor for CLBBB with symmetrical double‐disk device, longer operation time, which might result from edema and inflammation of conduction tissue caused by repeated passage of small PmVSD, was the only risk factor for CLBBB after transcatheter closure of PmVSD using ADO‐II. On the basis of these findings, we suggested that transcatheter closure of PmVSD using ADO‐II was technically effective, with several advantages, and could be attempted in PmVSD with hemodynamic changes. However, for asymptomatic children with small size of PmVSD, regular follow‐up might be a better choice because higher incidence of postprocedural conduction abnormalities and the possibility of sustained CLBBB were observed despite the use of the softer device of ADO‐II.Sources of FundingThis study was funded by grants from the National Key R&D Program of China (No. 2018YFC1002301), National Natural Science Foundation of China (Nos. 81800288 and 81971457), and Science‐Technology Support Plan Projects in Sichuan Province (Nos. 2017SZ0117, 2020YFS0017, and 2020YFS0101). This study was also supported by the Fundamental Research Funds for the Central Universities.DisclosuresThe data that support the findings of this study are available from the corresponding author upon reasonable request. There were no any conflicts of interest need to disclosure.Table 1. Risk Factors for Occurrence of CLBBB After Transcatheter Closure of PmVSD Using ADO‐IIVariablesAll patients (n=244)Nonarrhythmia group (n=157)CLBBB group (n=8)P valueBody weight, kg13.5 (7.0–46.0, 14.8±5.3)13.0 (8.5–33.5, 14.1±4.2)11.3 (7.0–16.0, 11.4±2.7)0.073*Age, mo34.0 (17.0–166.0, 41.6±24.6)31.0 (17.0–134.0, 37.6±18.1)26.5 (22.0–38.0, 28.1±5.9)0.144*Sex, n (%)Male128 (52.5)82 (52.2)4 (50.0)1.000†Female116 (47.5)75 (47.8)4 (50.0)…Inlet diameter of VSD on echocardiography, mm5.0 (1.5–16.0, 5.3±2.3)5.0 (1.5–12.0, 5.1±2.2)4.5 (2.0–8.0, 4.8±2.0)0.538*Outlet diameter of VSD on echocardiography, mm3.0 (1.5–6.0, 3.1±0.9)3.0 (1.5–5.0, 3.0±0.9)3.0 (2.0–5.0, 3.1±0.9)0.982*Subaortic rim on echocardiography, mm1.0 (0.0–6.0, 1.2±1.4)1.0 (0.0–6.0, 1.2±1.4)1.5 (0.0–2.0, 1.1±0.9)0.966*VSD size by angiography, mm2.0 (1.0–5.0, 2.1±0.6)2.0 (1.0–4.5, 2.0±0.5)2.0 (1.5–3.2, 2.2±0.6)0.254*QP:QS1.7 (1.3–4.5, 2.0±0.7)1.7 (1.3–4.3, 1.9±0.6)1.7 (1.5–3.3, 2.0±0.6)0.839*Delivery sheath, n (%)4F167 (68.4)116 (73.9)4 (50.0)0.215†5F77 (31.6)41 (26.1)4 (50.0)…Occluder size, mm3.0 (3.0–6.0, 3.3±0.6)3.0 (3.0–5.0, 3.2±0.5)3.0 (3.0–6.0, 3.5±1.0)0.509*Antegrade approach, n (%)180 (73.8)119 (75.8)7 (87.5)0.682†Retrograde approach, n (%)64 (26.2)38 (24.2)1 (12.5)…Operation time, min35.0 (15.0–150.0, 40.3±20.8)35.0 (15.0–130.0, 37.6±16.8)52.5 (40.0–100.0, 60.6±20.5)<0.001*,‡Fluoroscopic time, min5.0 (1.0–75.0, 8.0±9.2)5.0 (1.0–75.0, 7.1±8.2)8.0 (5.0–24.0, 12.8±8.6)0.131*Radiation dosage, mGy52.0 (13.0–574.0, 63.0±43.1)51.0 (13.0–574.0, 60.1±48.5)70.5 (48.0–188.0, 94.0±59.9)0.059*John Wiley & Sons, LtdData are expressed as median (range, mean±SD) or number (percentage). ADO‐II indicates Amplatzer duct occluder II; CLBBB, complete left bundle‐brunch block; PmVSD, perimembranous VSD; QP:QS, pulmonary/systemic flow ratio; and VSD, ventricular septal defect.*Z values.†χ2 values.‡P values <0.05 that the variable has a statistical difference between the nonarrhythmia group and the CLBBB group.AcknowledgmentsAuthor contributions: Dr Tang: data collection and analyses and writing original draft and review; Dr Shao: data collection and analyses; Dr Zhou: supervision and editing assistance; Dr Hua: supervision and study conduct; Dr Luo: editing assistance; Dr Wang: study conduct and writing review. All authors have provided permission to corresponding author for publication in the journal.Footnotes* Correspondence to: Chuan Wang, MD, Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan 610041, China. E‐mail: [email protected]com*C. Tang and S. Shao contributed equally to this article.For Sources of Funding and Disclosures, see page 3.See Editorial by Shahanavaz et al.References1 Koneti NR, Sreeram N, Penumatsa RR, Arramraj SK, Karunakar V, Trieschmann U. Transcatheter retrograde closure of perimembranous ventricular septal defects in children with the Amplatzer duct occluder II device. J Am Coll Cardiol. 2012; 60:2421–2422. doi: 10.1016/j.jacc.2012.08.1004CrossrefMedlineGoogle Scholar2 Ghosh S, Sridhar A, Sivaprakasam M. Complete heart block following transcatheter closure of perimembranous VSD using Amplatzer duct occluder II. Catheter Cardiovasc Interv. 2018; 92:921–924. doi: 10.1002/ccd.27177CrossrefMedlineGoogle Scholar3 Wang C, Zhou K, Luo C, Shao S, Shi X, Li Y, Wei L, Yan S, Liu X, Hua Y. Complete left bundle branch block after transcatheter closure of perimembranous ventricular septal defect. JACC Cardiovasc Interv. 2019; 12:1631–1633. doi: 10.1016/j.jcin.2019.04.043CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByShahanavaz S, Winlaw D and Opotowsky A (2022) What Is Blocking Transcatheter Ventricular Septal Defect Closure?, Journal of the American Heart Association, 11:7, Online publication date: 5-Apr-2022.Related articlesWhat Is Blocking Transcatheter Ventricular Septal Defect Closure?Shabana Shahanavaz, et al. Journal of the American Heart Association. 2022;11 April 5, 2022Vol 11, Issue 7Article InformationMetrics Copyright © 2022 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.121.022651PMID: 35350872 Manuscript receivedJuly 20, 2021Manuscript acceptedDecember 3, 2021Originally publishedMarch 30, 2022 Keywordstranscatheter closureAmplatzer duct occluder II deviceperimembranous ventricular septal defectcomplete left bundle‐branch blockPDF download SubjectsArrhythmiasClinical Studies
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