Historical Background
In terms of surgical closure of multiple defects in general, the
landmark experience was reported by Kirklin and colleagues in
1980.1 They reported hospital mortality of 14%, and a
need for reoperation to close residual defects in 28%. With regard to
the Swiss-cheese septum, in an attempt hermetically to close all
defects, and avoid a left ventriculotomy, Kitagawa and colleagues, in
1998, described the technique of using an oversized patch placed into
the left ventricle via the right atrium.2 As an
alternative, they also described the “sandwich technique”, achieved by
transfixing the muscular edge of the defects to the anterior free wall
of the ventricle after transecting the moderator band and right
ventricular trabeculations to provide optimal
exposure.2 Subsequent to this account, again with
regard to the Swiss-cheese septum, Black and colleagues, in 2000,
described closure of the defects using a single large autologous
pericardial patch.3 Cetin and colleagues, in 2005, in
contrast, used a composite patch of pericardium and Dacron graft. Both
patches were placed using a right atrial approach.4Mace and colleagues then suggested placing several intermediate fixation
stitches to prevent septal bulging.5 In 2001,
Yamaguchi and associates had described a “felt sandwich technique”.
This involved sandwiching the septum itself between two polyester felt
patches placed in the left and right ventricles without need for
ventriculotomy.6,7 Brizard and associates, in 2004,
reported a similar technique using intraoperative echocardiography
guidelines with excellent results.8 In 2006, Alsoufi
and colleagues described transatrial re-endocardialization without
dividing any trabeculations or the moderator band.9Much earlier, Stark and associates, in 1992, had closed the defects
using a fibrin seal of human origin.10
At a much earlier date, Aaron and Lower, in 1975, had indicated that
exposure and repair could be much easier when seemingly multipl defects
were approached through the left ventricle.11 This was
because, as we showed in our anatomical review, a solitary left
ventricular opening was often viewed as multiple orifices seen from the
right ventricular aspect. As we also explained in our first part,
however, this variant is not the same as the Swiss-cheese septum. And.
although this approach can facilitate the repair, debate has continued
regarding its potential sequels of a left ventriculotomy. Surgical
exposure through a left ventriculotomy can also, at times, be
disappointing. With the problems of a left ventriculotomy in mind,
therefore, others have advocated and demonstrated the safety and
effectiveness of an apical right ventriculotomy.12-15Still others have proposed a two-staged approach, with an initial band
placed on the pulmonary trunk, but this strategy has its own inherent
morbidity and mortality.16,17
Transcatheter closure is now well recognized as an additional
therapeutic option for closure of ventricular septal defects. The option
was first reported by Lock and associates from Boston using the Rashkind
devices.18 Then, in the late 1990s, a Nitinol device
was added to the armamentarium of the
interventionist.19-21 The interventional approach may
be particularly suitable for multiple muscular septal defects located in
the mid, apical, posterior, and anterior parts of the muscular
septum.20-30 For most cardiac centers, however,
devices delivered via catheters are not recommended in neonates and
infants because of the need for a stiff guide wire. This can rupture the
mitral valve, tear the septum, or invoke ventricular arrhythmias and
cardiac arrest. In the new millennium, nonetheless, multiple groups have
reported intraoperative perventricular closure, with encouraging early
outcomes.22-28