Conclusions
Based on the published literature, we conclude that color-Doppler flow mapping should allow precise delineation of the number, size, and location of multiple defects in infants and children, and facilitate planning of optimal strategy for intervention. The closure of Swiss-cheese defects still presents a technical challenge, and carries increased mortality. Use of an adjustable pulmonary arterial band is a desirable option in premature infants with low body weight, and body surface area less than 0.4m2, as it allows possible spontaneous closure of some smaller defects. Following its use, other defects can safely be closed on a bigger heart. Although oversized and Sandwich patch techniques are recommended for reconstituting the Swiss-cheese septum, biologic glue appears useful. Its downside is the need for extensive division or transection of right ventricular trabeculations for optimal visualization, with the potential long-term risk of myocardial and septal dysfunction.
Apical left or right ventriculotomies reliably provide access to apical defects, simplifying placement of patches, preserving ventricular volume compliance, and avoiding complications related to transection of trabeculations. With the current development of device closure, left ventriculotomy may be replaced in highly specialized centers by transcatheter or hybrid procedures. Perventricular device closure is here to stay. This means that surgeons should firmly embrace and study this new technology. For most teams, nonetheless, interventional or hybrid procedures are not recommended in premature infants, nor for those with low body weight or with the true Swiss-cheese septum.