"Swiss cheese" septal defects: surgical closure using a single patch with intermediate fixings

A review of the therapeutic management of multiple ventricular septal defects

BACKGROUND AND AIM

We showed in our anatomical review, ventricular septal defects existing as multiple entities can be considered in terms of three major subsets. We address here the diagnostic challenges, associated anomalies, the role and techniques of surgical instead of interventional closure, and the outcomes, including reinterventions, for each subset.

METHODS

We reviewed 80 published investigations, noting radiographic findings, and the results of clinical imaging elucidating the location, number, size of septal defects, associated anomalies, and the effect of severe pulmonary hypertension.

RESULTS

Overall, perioperative mortality for treatment of residual multiple defects has been cited to be between 0% and 14.2%, with morbidity estimated between 6% and 13%. Perioperative mortality is twice as high for perimembranous compared to muscular defects, with the need for reoperation being over four times higher. Perventricular hybrid approaches are useful for the closure of high anterior or apical defects. Overall, the results have been unsatisfactory. Pooled data reveals incidences between 2.8% and 45% for device-related adverse events. Currently, however, outcomes cannot be assessed on the basis of the different anatomical subsets.

CONCLUSIONS

We have addressed the approaches, and the results, of therapeutic treatment in terms of coexisting discrete defects, the Swiss-cheese septum, and the arrangement in which a solitary apical muscular defect gives the impression of multiple defects when viewed from the right ventricular aspect. Treatment should vary according to the specific combination of defects.

Biventricular surgical repair of "Swiss Cheese" ventricular septal defects with two-patch and right ventricle apex excluding technique: preliminary experience and clinical results

Background

“Swiss Cheese” ventricular septal defects (VSDs) is a kind of rare and complex congenital heart defects and the surgical management remains controversial and a challenge. We reviewed our preliminary clinical experience on biventricular surgical repair of “Swiss Cheese” VSDs with two-patch and right ventricle apex excluding technique in 10 cases.

Methods

From May 2014 to December 2019, a series of 10 patients (M/F = 3/7) were admitted in our center. Nine cases underwent one-stage surgical repair with two-patch and right ventricle apex excluding technique and 1 case received two-stage surgical repair with the same technique. Surgical repair was done with cardiopulmonary bypass (CPB) in all cases. Two fresh autologous pericardium patches were used to close defects of the outflow tract area and the apex trabecular area respectively and as a result, the right ventricular apex was excluded from the right ventricular inflow tract.

Results

All operations were successful. Median CPB time and aortic clamping time were 96 min and 68 min respectively. Delayed chest closure was performed in 2 cases within 48–72 h postoperatively. The Median time of mechanical ventilation and ICU stay were 131.3 h and 8 days respectively. Median length of hospital stay after operation was 11 (9–42) days. There was no mortality and major complication except for 2 cases of ventilator associated pneumonia. There was no death and major complication during a median follow-up time of 3.2 years.. The latest echocardiography results showed the left and right heart function was normal in all the cases.

Conclusions

Biventricular surgical repair of “Swiss Cheese” VSDs with two-patch of fresh autologous pericardium and right ventricle apex excluding technique in infants is safe and feasible with favorable early and mid-term results. Long term results need to be evaluated with more cases.

Intraoperative customized double-patch device with twin sutures for multiple muscular septal defects

OBJECTIVES

Closure of multiple muscular ventricular septal defects (VSDs) remains a challenge because of anatomical complexity.

METHODS

We mapped all the VSDs using en face reconstruction of the right ventricular septal surface through echocardiography and then performed an 'Intraoperative Customized Double-Patch Device' technique to surgically close them in 39 patients (male:female = 25:14). The median age of the patients was 6 months (2 months-10 years), and mean weight was 5.98 ± 4.21 kg. A patch of polytetrafluoroethylene was placed on the left ventricular side of the defect and another on the right ventricular side, and they were anchored to each other using 2 polypropylene sutures. Residual shunts were evaluated using intraoperative echocardiography and measurements of right atrial-pulmonary arterial saturation were taken in all patients.

RESULTS

The distribution of muscular VSDs was as follows: anterior muscular 12, posterior muscular 18, mid-muscular 11 and apical 9. The associated lesions included perimembranous VSD (n = 28), tetralogy of Fallot (n = 6), double-outlet right ventricle (n = 2) and supramitral membrane (n = 2). Mean clamp time and bypass time were 93 ± 19 min and 147 ± 26 min, respectively. Mean hospital stay was 11 ± 3.39 days with no in-hospital mortality. Five patients with significant residual shunts needed concomitant PA banding. All patients remained in New York Heart Association Class I. There was either no residual shunt (n = 3) or trivial shunt (n = 2) among the banded patients. All patients remained symptom-free and continued to thrive well at the most recent follow-up (3.48 ± 1.51 years).

CONCLUSIONS

Muscular VSDs can be mapped through en face reconstruction and closed using intraoperative customized double-patch device technique in a variety of situations with satisfactory immediate and short-term results.

A Simple Technique for Closing Multiple Muscular and Apical Ventricular Septal Defects

BACKGROUND

Multiple ventricular septal defects (VSDs) are difficult to close. In this report, we describe a simple and safe technique of closing multiple muscular and apical VSDs.

METHODS

Between January 2010 and December 2013, 52 patients with a muscular VSD either in isolation or in association with other congenital heart disease underwent surgery using this technique in which a black silk thread was passed through the suspected VSD opening into the left ventricle and brought out through the mitral valve and the interatrial septum. Sutures were placed around the silk thread to close the VSD.

RESULTS

Out of 52 patients, 34 were male; age ranged from 45 days to 5.5 years. In addition to the large subaortic/lage muscular VSD, three additional VSDs were present in 34 patients, two additional VSDs were present in 13 patients, and five patients had "Swiss Cheese septum." The VSDs were mid-muscular in 35 patients and were apical in 17 patients. Eleven patients had associated complex lesions. Intraoperative transesophageal echocardiograms did not reveal any significant residual shunt in any of these patients. There was no step-up on oximetry. There was one hospital death due to sepsis. Follow-up was available in 48 patients; three patients were lost to follow-up. At follow-up, no patient had a residual VSD.

CONCLUSION

The biventricular approach through trans-right atrial, trans-interatrial septum using a thread through the hole method for closing multiple muscular VSD is effective with no persistent residual defects.

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

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.

Long-term complications following surgical patch closure of multiple muscular ventricular septal defects

BACKGROUND

Multiple muscular ventricular septal defects (VSDs) in children can be difficult to treat and a range of techniques has been advocated. These include pulmonary artery banding, interventional catheter closure, and a variety of surgical approaches. When there are apical muscular defects and associated coarse trabeculations in the right ventricle (RV) producing a "Swiss cheese" pattern, a large patch extending on to the RV free wall and excluding part of the apex has been used.

METHODS

We assessed four adult patients who had surgery 22 to 45 years ago to treat muscular VSD by patches which excluded the RV apex.

RESULTS

Ages ranged from 22 to 50 years. Re-presentations were for polycythemia, cyanosis, syncope, and atrial flutter. Echocardiography showed bidirectional flow from left ventricle to apex of RV, no pulmonary hypertension, small-sized RV with diastolic dysfunction, enlarged right atria, reopening of patent foramen ovale (PFO) in three, and positive bubble studies with right to left shunting in two. Catheterization confirmed elevated right atrial and RV end diastolic pressures. Two patients had evidence of hepatic cirrhosis. One woman had device closure of PFO, but has right heart failure. One man had redo surgical closure of VSD and PFO. Another patient is being considered for a Glenn shunt to take some load off RV.

CONCLUSIONS

Surgical closure of muscular VSD by large patch with RV apical exclusion gives good early results. However, long term in adult life, the reduced size of RV, and diastolic dysfunction cause problems. These include reopening of PFO with cyanosis, right heart failure, cirrhosis, and arrhythmias.

Successful repair of multiple muscular ventricular septal defects using a unique hybrid procedure

The surgical management of multiple muscular ventricular septal defects (mVSDs) in the infant remains a challenging problem because of the presence of residual shunts and postoperative myocardial dysfunction. We present a case of successful repair of multiple mVSDs with a unique hybrid procedure combining both the perventricular closure and open surgical repair.

Closure of multiple ventricular septal defects by the felt sandwich technique: Further analysis of 36 patients

OBJECTIVES

We previously described a novel technique for closure of trabecular ventricular septal defects by sandwiching the septum with 2 polyester felt patches without requiring left ventriculotomy. We describe the midterm results of this technique and the postoperative cardiac function.

METHODS

This is a retrospective study of 36 consecutive patients. The median age and body weight at the time of repair was 15 months (range: 2-115 months) and 7.8 kg (range: 3.9-51.9 kg), respectively.

RESULTS

Sixty-three trabecular ventricular septal defects in 36 patients were closed with the felt sandwich technique. In the early postoperative period, 1 patient died of pulmonary hypertensive crisis. There were 2 late deaths. One patient died of pneumonia 6 months after surgery, and another died suddenly of ventricular arrhythmias 2 years after surgery. Three patients required reoperation (closure of major residual ventricular septal defect, cardiac transplantation for dilated cardiomyopathy, and pacemaker implantation for complete atrioventricular block). Postoperative left ventricular fractional shortening in the group with a body surface area less than 0.4 m2 was significantly lower than that in the group with a body surface area of 0.4 m2 or greater (0.22 +/- 0.09 vs 0.31 +/- 0.06, P = .0027). Moreover, there was a strong correlation between postoperative left ventricular ejection fraction and total patch area/body surface area ratio (R = -0.74, P = .0004).

CONCLUSION

Multiple trabecular ventricular septal defects can be closed with the felt sandwich technique easily and safely. Although this technique can be used in small infants, the use of numerous felt patches disturbs the movement of ventricular septum, which may cause postoperative cardiac dysfunction.

Percutaneous closure of postoperative ventricular septal defects with the amplatzer device

The objective of this study was to look at the procedure, the results, and the follow-up of patients who underwent percutaneous closure of a residual ventricular septal defect (VSD) following a surgical closure using the Amplatzer VSD device. Four patients had an original diagnosis of tetralogy of Fallot, two patients had a patch leak following a surgical repair of a VSD, and three patients had a VSD not repaired at the time of surgery. All patients fulfilled the currently accepted surgical criterion for reoperation (Qp/Qs>1.5). The mean Qp/Qs was 1.8+/-0.3 (1.5-2.3). Four patients underwent VSD closure using an Amplatzer perimembranous VSD device and in five patients an Amplatzer muscular VSD device was implanted. We performed percutaneous closure in nine patients. The size of the residual shunt ranged from 6 to 14 mm and the size of device used ranged from 8 to 16 mm. The arteriovenous loop needed to be recreated in two patients because of failure to advance the delivery sheath. There was complete closure of the defect in six cases, and a small residual shunt remained in three cases. Percutaneous closure of postoperative VSDs appears to be an effective way to resolve a hemodynamically significant residual shunt. There were no difficulties encountered with implantation of the devices. These promising short-term results need reinforcement with additional long-term data.

Repair of multiple muscular ventricular septal defects: septal obliteration technique

BACKGROUND

The management of the apical multiple muscular ventricular septal defects (VSDs) remains still controversial. There are various surgical techniques and approaches for closure of "Swiss-cheese" VSDs. In this study, we report the outcome of multiple muscular VSDs repair, using the septal obliteration technique.

METHODS

We used the septal obliteration technique in five "Swiss-cheese" ventricular septal defects cases through right atriotomy. Four of the cases had isolated multiple VSDs. One case also had an aortic arch interruption type A, which was repaired prior to cardiopulmonary bypass. Their ages varied between 43 days and 6 years.

RESULTS

We did not experience any mortality or serious morbidity. Tracheostomy was required in one patient. There was no important residual shunt in postoperative period, except a minimal shunt in one case.

CONCLUSION

The closure technique of "Swiss-cheese" trabecular multiple VSDs using a large single patch was not troubling. Transatrial approach prevented postoperative problems of ventricular incision. Using a large needle with a large pledgett is the key, which provides deep tissue penetration to avoid residual shunt.

New approach to multiple ventricular septal defect closure with intraoperative echocardiography and double patches sandwiching the septum

OBJECTIVE

This was an evaluation of a new approach to the management of multiple muscular ventricular septal defects. The defects were located with epicardial echocardiography, then transfixed with a guide wire inserted directly through the right ventricular free wall. They were closed with a custom-made multilayered double-patch device under cardioplegic arrest through a standard right atriotomy.

METHODS

This was a retrospective study of 14 consecutive patients.

RESULTS

The median age and body weight at repair were 40 days (range 1 week-8 years, 3 months) and 4.1 kg (2.8-24 kg), respectively. Five patients (36%) had undergone at least one previous sternotomy; 11 patients (78%) had associated cardiac lesions. Closure of the multiple septal defects was successful in 12 patients (85%). Failure to localize all defects led to pulmonary artery banding in 2 patients. One patient had the residual septal defect closed with a percutaneous device 6 months later, and in the second patient the residual defect was closed with a conventional approach 11 months afterward. Two patients had permanent pacemaker insertion. In 279 patient-months of follow-up, there was 1 cardiac arrest on day 1 and no early or late deaths; all children but one are free of cardiac medications, and no significant residual left-to-right shunts were demonstrated in any patient.

CONCLUSION

The reported management of multiple ventricular septal defects has been successful in this series, even in neonates and infants with complex associated cardiac lesions. It appears safe, simple, and effective.

Surgical management of trabecular ventricular septal defects: the sandwich technique

BACKGROUND

Surgical closure of trabecular ventricular septal defects is difficult and often unsuccessful.

OBJECTIVE

We performed closure of trabecular ventricular septal defects by sandwiching the septum between 2 polyester felt patches placed in the left ventricle and right ventricle without ventriculotomy.

METHODS

Eleven patients (7 boys and 4 girls) underwent a sandwiching closure at a mean age of 4.7 years (range, 0.4-9.7 years) and a mean weight of 16.7 kg (range, 4.6-52 kg). Associated cardiac malformations were present in 9 of the 11 patients. Seven patients had undergone previous operations. The trabecular ventricular septal defects are exposed through the tricuspid valve and also from the left ventricular side through a coexisting large perimembranous ventricular septal defect or through the mitral valve through an interatrial septostomy. Two forceps, one each from the right and left ventricular side, lead a 3F Nelaton catheter through the trabecular defect. An oversized circular polyester felt patch mounted on a 3-0 Nespolen suture attached to the Nelaton catheter is then passed into the left ventricle. The suture ends are then passed through a slightly smaller polyester felt patch on the right ventricular side of the septum. The Nespolen suture is then tied, thereby sandwiching the septum between the 2 patches.

RESULTS

Time required for the procedure was less than 20 minutes in each case. There were no hospital deaths, and the postoperative course was uneventful in all patients. There was no residual shunt in 3 patients, and a minimal residual shunt was observed in 5 patients. Mild residual shunt was observed in 3 patients. Cardiac catheterization was performed 1 month postoperatively in 8 patients in whom residual shunt was noted on echocardiography. Five of 8 patients had a minimal residual shunt (pulmonary blood flow/systemic blood flow ratio = 1.0). Three patients had a residual shunt (pulmonary blood flow/systemic blood flow ratio = 2.0, 1.6, and 1.2). The patient with a pulmonary blood flow/systemic blood flow ratio of 2.0 had a "Swiss cheese" ventricular septal defect, and a residual shunt remained around the patch. However, the residual shunt decreased to a pulmonary blood flow/systemic blood flow ratio of 1.6 at examination 16 months postoperatively. Echocardiography showed that the residual shunt had also decreased in another 2 patients.

CONCLUSIONS

We conclude that the sandwich technique is safe and easy. Even in cases with a residual shunt present, the shunt is expected to decrease as time passes. Further experience and longer follow-up of these patients are necessary to conclude whether this technique is applicable to neonates and young infants.

Catheter therapy of Swiss cheese ventricular septal defects using the Amplatzer muscular VSD occluder

The medical and surgical management of patients with multiple muscular ventricular septal defects (VSDs) is associated with morbidity and mortality. Three children with Swiss cheese VSDs were treated with transcatheter occlusion of their multiple defects using the Amplatzer muscular VSD occluder. Seventeen defects were closed in five catheterization procedures. One patient had three devices placed in two procedures, the second had five defects closed in one procedure, and the third had nine defects closed in two procedures. Two patients had previously been treated with pulmonary artery banding and required subsequent surgical band removal. There was immediate reduction in the left-to-right shunting and clinical improvement in all patients. Complications included the need for blood transfusion during the two longest procedures and tricuspid valve regurgitation in one. Transcatheter occlusion of multiple VSDs is an acceptable alternative or adjunct to surgical therapy for these complex patients.

Outcomes of intraoperative device closure of muscular ventricular septal defects

BACKGROUND

The surgical management of muscular ventricular septal defects (mVSD) in the small infant is a challenge particularly when multiple and associated with complex cardiac lesions. Devices for percutaneous implantation have the advantage of ease of placement and for the double umbrella designs a wide area of coverage. We reviewed our experience and clinical outcomes of intraoperative mVSD device closure for such defects in small infants.

METHODS

Since October 1989, intraoperative VSD device closure was a component of the surgical strategy in 14 consecutive patient implants (median age, 5.5 months; range, 3 to 11 kg), whose defects were thought difficult to approach using conventional techniques. Nine patients had associated complex cardiac lesions, 10 multiple mVSDs, and 4 patients had a previous pulmonary artery banding.

RESULTS

There were 2 early deaths, 1 in a severely ill child who preoperatively had pulmonary hypertension and left ventricular failure and another in a patient with a hypoplastic left heart. Mean pulmonary to systemic flow ratio before device insertion was 3.5:1. Complete closure was achieved in 5 patients and clinically insignificant residual shunts persisted in 7. In 2 infants with significant residual lesions concomitant pulmonary artery banding was required. Postoperative mean pulmonary to systemic flow ratio was 1.7:1. In follow-up of the 12 surviving infants (mean, 41 months), 8 had complete closure and 3 persistent residual shunts. One patient with no residual shunting required heart transplantation for progressive ventricular failure 9 years after operation. All devices were well positioned on postoperative echocardiograms. There was 1 late death due to aspiration in a patient with a tiny residual shunt.

CONCLUSIONS

Infants requiring operative intervention with mVSDs are difficult to manage and have an increased mortality and morbidity. Intraoperative VSD device placement for closure of mVSDs is feasible, can avoid ventriculotomy, division of intracardiac muscle bands, and is ideally suited for the neonate or infant.