Hybrid closure of multiple apical muscular septal defects
Hybrid, perventricular delivery of the device involves direct access to the right ventricle via a surgical incision, which may be median sternotomy, or a limited subxiphoid, parasternal or infra-axillary incision.23-25,51-55,69 The procedure is performed on a beating heart without fluoroscopy using continuous transesophageal or epicardial echocardiographic guidance. The approach to device delivery include direct puncture into the right ventricle, direct transthoracic puncture, and placement with the heart open under cardiopulmonary bypass.55,68 In some institutions, device closure is the treatment of choice if the defect is difficult to access, such as in the apical or anterior muscular septum, and in the setting of the Swiss-cheese septum.19-28,51-55