Device closure of multiple midmuscular septal defects
In cases of multiple septal defects separated by a moderate margin,
double and triple devices have been inserted, either by a hybrid
approach or percutaneously. in select
institutions.21-28,52-55
Combined perimembranous and inlet muscular septal defects
Black and associates used a standard patch to close the perimembranous
defect, and inserted a pericardial patch to obliterate the associated
muscular ventricular septal defect.3 Serraf and
associates also used a patch to close the perimembraneous defect, but
used pledget-reinforced mattress sutures for the smaller muscular
defect.43 Alsoufi and associates used separate patches
to close combined perimembranous and muscular defects, but used Dacron
patches to close large apical defects located underneath the moderator
band.9 These latter authors employed a strategy of
re-endocardialization for associated smaller septal defects without
dividing any major trabeculations. using double-layered suturing of the
septal trabeculations with fine, superficial, subendocardial running
sutures.9 Yashimura and associates closed the
perimembranous defects using a Dacron polyester patch. Like Serraf and
colleagues, they used pledget reinforced mattress sutures for the
muscular defects, or re-endocardialisation using 6-0
prolene.44 Closure of these ventricular septal defects
using separate patches, however, entails the risks of surgical complete
heart block, since the conduction axis runs in between two ventricular
septal defects.38,43 Because of this, closure has been
recommended and practiced using a single patch. Another option is to
temporize by banding the pulmonary trunk, as described above,
anticipating that growth will facilitate the placement of separate
patches (see below).