Transesophageal Echocardiography-Guided Device Occlusion of Ventricular Septal Defects: A Propensity Score Matching Analysis of Left Anterior Mini-Thoracotomy vs. Lower Partial Median Sternotomy

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Transesophageal Echocardiography-Guided Device Occlusion of Ventricular Septal Defects: A Propensity Score Matching Analysis of Left Anterior Mini-Thoracotomy vs. Lower Partial Median Sternotomy

Ventricular septal defect (VSD), accounting for 40% of congenital cardiac malformations, has traditionally been repaired via cardiopulmonary bypass surgery. While effective, this approach is invasive and associated with prolonged recovery. Percutaneous device closure, though minimally invasive, is unsuitable for all VSD subtypes. Transesophageal echocardiography (TEE)-guided transthoracic device occlusion has emerged as a promising alternative, combining minimally invasive techniques with real-time imaging. This study evaluates two surgical approaches for TEE-guided VSD closure: left anterior mini-thoracotomy (LAMT) and lower partial median sternotomy (LPMS), comparing their technical feasibility, clinical outcomes, and cost-effectiveness.

Patient Characteristics and Study Design

A retrospective analysis included 156 patients undergoing TEE-guided VSD closure at Lanzhou University Second Hospital between 2013 and 2018. Patients were divided into LPMS (n=80) and LAMT (n=76) groups. Propensity score matching (PSM) was applied to address baseline differences, yielding balanced cohorts of 33 patients per group. Pre-PSM, LAMT patients were older (1–5 vs. 2–21 years, P<0.001) and heavier (11.75–49.25 vs. 8.38–17.63 kg, P<0.001) than LPMS patients. Post-PSM, demographics, VSD size, and morphology were comparable.

Surgical Techniques

Both procedures were performed under general anesthesia with TEE guidance.

Incision and Access

  • LPMS: A limited midline sternotomy provided direct access to the right ventricular surface. The perpendicular angle of sheath insertion relative to the VSD plane facilitated occluder deployment, particularly for defects with large left ventricular diameters (8–15 mm).
  • LAMT: A 1-cm incision in the third or fourth left intercostal space minimized sternal trauma. The third intercostal approach targeted supracristal and perimembranous outflow VSDs, while the fourth space was used for muscular and perimembranous inflow defects. The delivery sheath often required bending into an “L” shape to align with non-perpendicular VSD planes.

Device Delivery Methods

Two techniques were employed:

  1. One-Step Method: The occluder was preloaded into the delivery sheath, advanced through a purse-string suture on the epicardium, and deployed under TEE guidance after confirming sheath traversal across the VSD.
  2. Step-by-Step Method: A guidewire or hollow probe established a pathway through the thoracic incision (Figure 1A–B, 1E–F). The sheath or probe was advanced to the left ventricle via the VSD (Figure 1C–D). For probe-assisted cases, the probe was replaced with the sheath over the guidewire before occluder deployment.

Clinical Outcomes

Procedural Success and Complications

Successful VSD closure was achieved in 94.9% (148/156) of cases, with eight conversions to open surgery (5 LPMS, 3 LAMT). Causes included immediate complete atrioventricular block (n=3) and occluder displacement (n=5). No major complications occurred in either group, except one LPMS patient who died postoperatively from infective endocarditis.

Operative Metrics

  • Intracardiac Operation Time: No significant difference between LPMS and LAMT, either pre-PSM (8.6±4.1 vs. 9.9±5.8 min, P=0.087) or post-PSM (8.1±4.1 vs. 9.1±5.6 min, P=0.087).
  • Incision and Suture Time: LPMS required significantly longer times than LAMT pre-PSM (57.3±15.1 vs. 40.4±8.3 min, P<0.001) and post-PSM (57.6±14.0 vs. 41.0±9.0 min, P<0.001).

Postoperative Outcomes

  • Residual Shunts: Rates were comparable during hospitalization and at 3-month follow-up.
  • Valvular Regurgitation: Similar incidence of tricuspid/aortic regurgitation between groups.
  • Arrhythmias: No intergroup differences in postoperative arrhythmias.

Hospital Stay and Cost-Effectiveness

  • Pre-PSM: LAMT shortened hospital stays (11.8±5.3 vs. 14.6±7.9 days, P=0.012) but showed no cost difference (49,527±24,673 vs. 49,316±15,203 RMB, P=0.949). LPMS had better cost-effectiveness ratios (528.01 vs. non-significant LAMT).
  • Post-PSM: No differences in stay or cost, but LPMS remained more cost-effective (454.57 vs. 519.80).

Technical Considerations

  • LPMS Advantages: Optimal for younger, lighter patients and beginners. The direct approach simplifies sheath alignment, particularly for small VSDs (2–3 mm).
  • LAMT Advantages: Avoids sternal injury, reduces wound exudate, and enables faster recovery. The “L”-shaped sheath enhances maneuverability for complex VSDs.
  • Method Selection: The one-step method suits LPMS due to straightforward pathways, while the step-by-step method accommodates LAMT’s tortuous routes.

Limitations and Future Directions

The retrospective design and single-center data limit generalizability. Long-term outcomes, including device stability and valvular function, require further study. Prospective trials comparing these techniques with percutaneous approaches are warranted.

Conclusion

TEE-guided transthoracic VSD closure via LAMT or LPMS is safe and effective. LAMT offers minimal trauma and quicker recovery, while LPMS is preferable for younger patients and technically simpler cases. Individualized approach selection based on VSD anatomy and surgeon expertise optimizes outcomes.

doi.org/10.1097/CM9.0000000000001514

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