Fontan completion without surgery is suitable in patients with single ventricles with lower mortality and morbidity, avoids multiple surgical interventions while maintaining the staged approach and allows for successive dilatation of the Fontan pathway to accommodate for growth.

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Trivial to mild AVVR remains stable and their repair during the Fontan operation provides no additional benefits. Valve repair in patients with moderate to severe AVVR improved the regurgitation with comparable operative mortality and long-term outcome; however, similar benefits could be achieved without repair of the atrioventricular valve. We should not deny patients with similar AVVR the Fontan operation.

A variety of therapies are available to close ventricular septal defects (VSDs). These include surgical closure on bypass, percutaneous device closure, as well as perventricular hybrid closure. Due to the incidence of heart block (1-5%) associated with percutaneous device closure of perimembranous VSDs, surgical closure presently remains the gold standard and preferred therapy for these defects. Therapeutic options are more varied for muscular VSDs. Beyond infancy, transcatheter closure offers excellent results with low morbidity and mortality, without the need for cardiopulmonary bypass. Infants however have a higher incidence of adverse events using a percutaneous approach. Large mid-muscular VSDs in infants can be treated successfully using a hybrid approach, surgical closure on bypass or a percutaneous approach. However, VSDs located apically or anteriorly are difficult to identify surgically and for these infants, perventricular hybrid closure should be considered as the preferred therapeutic modality. However, some VSD's also can be closed percutaneously.

Diaphragmatic paralysis following phrenic nerve injury is a major complication following congenital cardiac surgery. In contrast to unilateral paralysis, patients with bilateral diaphragmatic paralysis present a higher risk group, require different management methods, and have poorer prognosis. We retrospectively analysed seven patients who had bilateral diaphragmatic paralysis following congenital heart surgery during the period from July, 2006 to July, 2014. Considerations were given to the time to diagnosis of diaphragm paralysis, total ventilator days, interval after plication, and lengths of ICU and hospital stays. The incidence of bilateral diaphragmatic paralysis was 0.68% with a median age of 2 months (0.6-12 months). There was one neonate and six infants with a median weight of 4 kg (3-7 kg); five patients underwent unilateral plication of the paradoxical diaphragm following recovery of the other side, whereas the remaining two patients who did not demonstrate a paradoxical movement were successfully weaned from the ventilator following recovery of function in one of the diaphragms. The median ventilation time for the whole group was 48 days (20-90 days). The median length of ICU stay was 46 days (24-110 days), and the median length of hospital stay was 50 days (30-116 days). None of the patients required tracheostomy for respiratory support and there were no mortalities, although all the patients except one developed ventilator-associated pneumonia. The outcome of different management options for bilateral diaphragmatic paralysis following surgery for CHD is discussed.