Techniques and results in the management of multiple muscular trabecular ventricular septal defects

Abstract

The management of patients with multiple muscular trabecular ventricular septal defects (VSDs) remains controversial. In the past two decades, innovative techniques including a right ventricular apical infundibulotomy and transcatheter, intraoperative and perventricular device closure have been exploited, and essential right atrial approach and limited apical left ventriculotomy have also been refined. However, specific management guidelines for this difficult disease have not been established. In this article, the benefits and drawbacks of each technique are reviewed and discussed. Primary repair for infants with multiple muscular trabecular VSDs was associated with good late outcomes. The right atrial approach was satisfactory for all muscular VSDs, excluding apical defects that were well seen through a limited apical ventriculotomy. Surgical closure of apical defects could be achieved safely and completely in early infancy through a limited apical left ventriculotomy or a right ventricular apical infundibulotomy. Further follow-up and prudent evaluations of ventriculotomy-associated morbidities are needed. Pulmonary artery banding should be limited to a small infant with complex associated defects. Percutaneous device closure, the most desirable option, is impractical due to limitations between the delivery system and access route. Intraoperative device closure appears less successful than device closure in the catheterization laboratory. Perventricular device closure has a significant advantage of being a non-bypass procedure approach. A less invasive strategy for "true" Swiss cheese septum is needed. All may have an important role, and results obtained by using these techniques are encouraging. These hybrid approaches will promise future success on management guidelines of multiple muscular trabecular VSDs.

Our Experience in 33 Patients of Multiple Ventricular Septal Defect Closure

“…Initial palliation with a pulmonary artery band has inherent morbidity and mortality and requires two stages. The added complexity during the second stage includes pericardial adhesions, need for pulmonary artery repair, and RV hypertrophy contributing to the difficult location and closure of the ventricular septal defect [3]- [6].…”

“…Kitagawa and colleagues [3] [4] used different techniques in 33 patients, one of which relies on the concept of an oversized patch placed on the LV side of the septum. Sutures were placed circumferentially through the patch and the rim of the ventricular septal defect from the LV side.…”

Popular Hybrid Congenital Heart Procedures without Cardiopulmonary Bypass

“…Traditionally, large muscular and perimembranous ventricular defects were closed via patch repair with surgery requiring cardiopulmonary bypass, with closure at times challenging due to location and periodically resulting in residual defects (21). The percutaneous approach with device closure was first described in 1988 (22), and with refinement over the years, has provided benefit in suitable cases.…”