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).