This leaflet aims to give you an overview of keyhole closure of ventricular septal defects.
Transcatheter closure of Ventricular Septal Defect
A ventricular septal defect (VSD) is a hole between the two main pumping chambers (ventricles) of the heart. Ventricular septal defects are the second most common cardiac defect, accounting for approximately a fifth of all congenital cardiac anomalies. The hole allows blood to cross from the left side of the heart to the right, leading to extra blood flow through the lungs. Holes of this kind can occur anywhere along the length of the dividing wall with the majority (80%) occurring “high” up in the septum towards one of the valves of the heart. This sort of defect is known as a perimembranous VSD. Defects lower down towards the bottom of the heart are called muscular VSD’s.
Normal Heart
Ventricular Septal Defect
Why does my defect (VSD) need closing?
Most large VSD’s cause problems related to breathlessness in babies during early life when the only treatment option available is open heart surgery.
The majority of smaller defects do not cause symptoms and never require any treatment at all. These defects are simply monitored over the years by a cardiologist or specialist nurse.
A small number of defects are small enough not to require treatment as a baby but large enough to put strain on the heart over a period of time, such that closure of the defect will benefit the patient. There are also circumstances (e.g. if the hole is close to a valve and it causes the valve to leak) where closing the hole is a good idea in the long term.
VSD’s can be associated with endocarditis (infection in the heart). If you have a VSD and have had endocarditis, we would recommend closure.
For some patients the hole can be closed with a plug delivered through a tube (catheter) using a keyhole technique rather than an open heart operation.
What are the advantages of keyhole treatment over open heart surgery?
There are two major advantages of keyhole treatment compared with open heart surgery. Firstly, the procedure avoids the need for an open heart operation, which leaves a scar and can be painful for a number of weeks. Secondly, in order to perform an
open-heart operation, the surgeon has to stop the heart and stitch the hole closed.
To do this a machine takes over the function of the heart (bypass). This process is associated with small complications (brain and other organ damage).
A keyhole procedure has a much shorter stay in hospital (1 day vs about 5-7 days), with no time on the intensive care unit and minimal postoperative pain. Most patients after a keyhole approach will be up and around the same evening and will be able to get back to normal activities within a couple of days.
What are the risks of keyhole VSD closure?
There is a small risk of the device dislodging and falling out, such that occasionally the device may need to be removed during the same procedure. If it is not possible to retrieve a dislodged device, an open heart operation can sometimes be required to remove the device and close the hole at the same time.
Electrical disturbances of the heart can occur during the procedure. Generally, these do not require treatment. There is a small risk of a slow heart rhythm (heart block) related to pressure from the plug on the electrical system in the heart. In some cases, a permanent pacemaker can be needed. At present we do not know the exact risk of heart block as a result of the procedure, but it seems to occur in between 1 and 5 % of cases reported in the scientific literature and depends very much on the position of the hole – for some patients there may be no risk at all.
There is a small risk of heart perforation or valve damage (less than 1 in 100) which may need emergency heart surgery.
There is a small risk of a residual leak around the device. Generally, this heals with time but there are rare reports of residual holes not closing and needing further treatment.
Occasionally residual holes can cause breakdown of red blood cells that can require another procedure. This is called haemolysis but is rare.
How do you close the hole?
We use a device (plug) made of a metal mesh. The device pictured below is called an Amplatzer device but there are other types and shapes of device used for VSD closure as well.
Amplatzer device
Acknowledgment
Amplatzer is a trademark of Abbott or its related companies.
Reproduced with permission of Abbott, © 2021.
All rights reserved.
The procedure is carried out under general anaesthetic. Firstly, we perform a TOE (an echo scan from the back of the throat) to get detailed pictures of the hole.
There is a small chance that this test may show something that means we cannot close the hole and we have to wake you up from the anaesthetic at this stage.
Catheters (tubes) are then placed in the vessels at the top of the leg and angiograms (pictures) taken of the hole. Using a range of wires, the device is positioned over the hole and after safety checks, is released. The whole procedure takes around 2 hours.
For a week before your procedure and around 6 months afterwards it will be necessary to take aspirin (75mg) to prevent small blood clots forming on the device. Sometimes this is needed lifelong. Occasionally another drug is also needed.
Ventricular Septal Defect – Video
Ventricular Septal Defect
This video explains the congenital heart condition Ventricular septal defect.
You may wish to view our video on normal heart function before viewing this. The part of the heart that pumps blood to the lungs via the pulmonary artery is called the right ventricle, and the part of the heart that pumps blood to the body via the aorta is called the left ventricle. The two ventricles are divided by the ventricular septum. A hole in the ventricular septum is called a ventricular septal defect, or VSD. When a VSD is present, some of the blood that should be pumped from the left ventricle to the aorta passes through the VSD to the right ventricle and then to the pulmonary artery.
This means that more blood flows to the lungs and flows to the body. The extra blood flow to the lungs returns to the left side of the heart, and if the VSD is large enough, it causes the left side of the heart to enlarge. The impact of a VSD largely depends on its size at one end of the spectrum. A large VSD results in a large amount of extra blood flow to the lungs and may cause problems such as difficulties with breathing and feeding shortly after birth. If larger VSTs are left untreated over time, the extra blood flow to the lungs can cause permanent damage to the arteries of the lungs.
On the other end of the spectrum, when a VST is small, there may only be a very small amount of extra blood flow to the lungs such that the left side of the heart does not become enlarged. Closing a ventricular septal defect most commonly requires open-heart surgery in which a patch of material is sewn over the hole, preventing blood from flowing through it and allowing the enlarged heart to reduce in size.
In some cases, in all the children and adults, smaller VSDs can be closed using a keyhole procedure rather than open-heart surgery. However, smaller vsts may not need to be treated, and some may even close by themselves. When a small BSD is left untreated, observation over time may be required because complications occasionally occur. For example, when the VSD is close to the aortic valve, the aortic valve can develop a leak so that some blood that has been pumped from the left ventricle to the aorta leaks back into the ventricle. There is also a risk of infective endocarditis, which means infection in the heart on an untreated VSD.
Do I have a choice?
Some patients decide that although their hole may be closable with a keyhole technique that they would prefer an open heart operation. A small number of patients will decide they do not want any form of treatment at all having understood all the risks.
If you choose not to have your VSD closed, you must take extra precautions to reduce your risk of getting endocarditis (good dental hygiene and regular dental check-ups, avoiding tattoos and piercings, being aware of the signs and symptoms of endocarditis).
Other information
You will receive a date for your procedure through the post. We try to give you around 4 weeks notice but it’s often not possible for us to give you more than a week or two notice of the date.
Contact the secretary
Please contact the secretary as soon as you receive your letter to confirm either by telephone or email.
This is very important
If you do not confirm in good time your slot will be offered to someone else.
Most people do not need longer than a week off work. You should avoid any heavy lifting/strenuous exercise and driving for 3-4 days until your leg is no longer sore. Most people will remain well and lead a completely normal life after VSD closure. No restrictions to physical activity are required. If you are taking an anticoagulant drug (blood thinner) this should be stopped in advance (usually around 3 days).
You will receive a telephone pre-assessment call approximately 2 weeks prior to the date of the procedure.
Please make sure you have had a dental check-up and that all outstanding dental work is complete before your VSD closure due to the small risk of endocarditis (infection in the heart). If you have not seen a dentist this may delay your procedure.
We appreciate it can be quite a wait between your clinic appointment and your procedure so, if in the time waiting for your procedure you have any questions or concerns, then please contact the specialist nursing team who will be happy to assist you.