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\begin{document}

\title{Letter to the Editor: Percardiac closure of large apical ventricular
septal defects in infants: Novel modifications and mid-term results}



\author[1]{Uroosh Tariq Khanzada}%
\affil[1]{Liaquat National Medical College}%


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  \date{May 27, 2024}


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\emph{Title page}

\textbf{Title} : Letter to the Editor: Percardiac closure of large
apical ventricular septal defects in infants: Novel modifications and
mid-term results

\section*{Article type: Letter to the
editor}

{\label{article-type-letter-to-the-editor}}

\textbf{Correspondence} : 1. Uroosh Tariq Khanzada

Contact: +14162546664 Email: urooshkhanzada@gmail.com

Institute: Liaquat National Medical College

Address: National Stadium Rd, Liaquat National Hospital, Karachi,
Karachi City, Sindh 74800

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\section*{Words count: 489}

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Conflict of interest: None

Declaration: None

Acknowledgment: None

Letter:

To the Editor,

The research entitled ''Percardiac closure of large apical ventricular
septal defects in infants: Novel modifications and mid-term results'' by
Geoffrey J. Changwe et al. gave me great pleasure to
review.\textsuperscript{1} This post was interesting and fruitful, and I
feel privileged to have read it. Pericardiac closure (PDC) of the apical
muscular ventricular septal defect (AmVSDs) is feasible, effective, and
safe, regardless of the patient's body weight along with residual shunt
(RS) rate, which is highly related to AmVSD morphology. During the late
followup period, RS among multiple holed AmVSDs remained unchanged.
While the periventricular approach was suitable for complex AmVSD, the
peratrial approach was less invasive, required less time, and yielded
superior cosmetic results. However, I am aware of the study's
limitations, and I believe alternative methodologies could improve and
strengthen the study's conclusions.

Firstly, some experts believe that the right atrial approach is the most
challenging way to close multiple apical ventricular septal defects;
thus, they advocate palliative surgery with pulmonary artery banding to
prevent congestive heart failure in infancy and enable the heart
cavities to develop. In addition to causing increasing right ventricular
hypertrophy and diastolic dysfunction, a pulmonary artery banding
procedure is associated with a high early postoperative death
rate.\textsuperscript{2} Small infants with apical muscular VSDs may be
challenging to close surgically due to inadequate direct visibility. At
the same time, percutaneous closure may be hampered by hemodynamic
instability caused by manipulating a great sheath via a wire rail.
Direct periventricular puncture of the RV-free wall (hybrid method) can
significantly enhance access to the defect and permit the implantation
of significant devices. In 1998 and in a recent multicenter analysis of
47 patients, this technique was initially disclosed. Given the magnitude
of the VSD and the possibility of pulmonary hypertension, our team
decided to attempt a hybrid method involving a surgical anchor for the
device. As device embolization can occur in 1\% to 2\% of
patients,\textsuperscript{3} an RV ''stay-suture'' was created to
prevent right-to-left device embolization. 3 The ideal surgical repair
requires the total closure of many flaws. In an ideal situation, the
moderator band and septomarginal trabeculation should stay intact,
without the necessity for ventriculotomy, without compromising the size
of the ventricular chambers, without causing ventricular dysfunction,
surgical total heart block, aortic and tricuspid regurgitation, and
without impeding coronary artery flow. Numerous surgical and
interventional procedures and short-term follow-up studies that reveal
an unfavorable incidence of perioperative mortality and morbidity
demonstrate that this ideal has not yet been attained.4 Proponents of an
apical right ventriculotomy have established the safety and efficacy of
this technique for large solitary apical lesions with several overlaying
trabeculations and for apical and anterior defects. A modest incision is
made in the right ventricle near to the left anterior interventricular
coronary artery without harming the blood vessel. According to Tsang and
colleagues, a ventriculotomy in this region provides access to the gap
between the papillary muscles and septum.\textsuperscript{4}

References:

\begin{enumerate}
\tightlist
\item
  Changwe GJ, Hongxin L, Zhang HZ, Wenbin G, Liang F, Cao XX, Chen SL.
  Percardiac closure of large apical ventricular septal defects in
  infants: Novel modifications and mid-term results. J Card Surg. 2021
  Mar;36(3):928-938. doi: 10.1111/jocs.15291. Epub 2021 Jan 27. PMID:
  33503678; PMCID: PMC7898510.
\item
  Perez-Negueruela C, Carretero J, Mayol J, Caffarena JM. Surgical
  closure of multiple large apical ventricular septal defects: how we do
  it. Cardiol Young. 2017 Apr;27(3):588-591. doi:
  10.1017/S1047951116001517. Epub 2017 Feb 6. PMID: 28162114.
\item
  Escobar AJ, Levi DS, Van Arsdell GS, Perens GS, Mohan UR. Apical
  muscular ventricular septal defect closure via hybrid approach using a
  right ventricular stay suture. Catheter Cardiovasc Interv. 2021
  Mar;97(4):E514-E517. doi: 10.1002/ccd.29370. Epub 2020 Nov 16. PMID:
  33197132.
\item
  Chowdhury UK, Anderson RH, Spicer DE, Sankhyan LK, George N, Pandey
  NN, Balaji A, Goja S, Malik V. A review of the therapeutic management
  of multiple ventricular septal defects. J Card Surg. 2022
  May;37(5):1361-1376. doi: 10.1111/jocs.16289. Epub 2022 Feb 11. PMID:
  35146802.
\end{enumerate}

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