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J Thorac Cardiovasc Surg 1999;117:402-403
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Technique to repair multiple muscular ventricular septal defects

We read with great interest the article by Kitagawa, Durham, Mosca, and Bove ¹ on the management of multiple ventricular septal defects (VSDs). We congratulate them on their excellent results and also on highlighting some important technical points. We would like to bring to the attention of our colleagues an additional technique, which has been used successfully in 5 patients at our center.

Often, multiple muscular VSDs are associated with a perimembranous VSD or have at least 1 defect that is relatively larger in dimension. We negotiate a right-angled forceps through the perimembranous VSD (via the right atrium). This permits the left ventricular side of the septum to be probed gently to locate the discrete (fewer) left-sided openings in this setting. An oversized stiff Teflon (polytetrafluoroethylene) patch mounted on a 4-0 Prolene suture (Ethicon, Inc, Somerville, NJ) is then passed into the left ventricle via the large VSD, gently negotiating the suture lengths through the muscular VSD toward the right ventricular side. The suture ends are then passed through a similar Teflon pledget on the right ventricular side of the septum. The Prolene suture is then tied firmly, thereby sandwiching the septum between the 2 stiff Teflon patches.

View larger version (43K): [in this window] [in a new window]   Fig 1. Multiple muscular VSDs most often have an associated perimembranous VSD. Negotiating a right-angled forceps through the perimembranous VSD (via the right atrium) permits the left ventricular side of the septum to be probed gently to locate the discrete left-sided openings in this setting. LV, Left ventricle; RV, right ventricle.

View larger version (21K): [in this window] [in a new window]   Fig 2. An oversized stiff Teflon (polytetrafluoroethylene) patch is passed into the left ventricle via the large VSD, gently negotiating the suture lengths through the muscular VSD toward the right ventricular side.

View larger version (57K): [in this window] [in a new window]   Fig 3. The suture ends are then passed through a similar Teflon patch on the right ventricular side of the septum.

View larger version (84K): [in this window] [in a new window]   Fig 4. The suture length is tied firmly, thereby sandwiching the septum between the 2 stiff Teflon patches.

1. It is easier to locate a VSD from the left side, because the septum has fewer trabeculae on that side and there would be fewer openings of the multiple VSD on that side.
   
2. The pressure in the left ventricle is higher than that in the right ventricle; hence an oversized patch on the left ventricular side is pushed against the septum and becomes "leak-proof."
   
3. The right ventricular side has multiple trabeculae that have to be meticulously cut to expose the muscular VSDs. In spite of that, the sutures placed on a right-sided patch often leave tracts between trabeculae that result in residual defects.
   
4. A left ventriculotomy should be avoided whenever possible.
   
5. The conduction bundle does not come near the muscular VSDs.
   

Placing a left-sided patch without opening the left ventricle, with its attendant risks, would thus seem the best way to tackle the problem of multiple muscular VSDs. It is here that our simple method scores over other more elaborate procedures. We abandoned the authors' method of placing multiple sutures in the oversized patch, because the procedure is cumbersome and tedious, as high-lighted by Dr John Brown ² in the discussion following the article. Instead, we find that passing the 2 ends of a 4-0 Prolene suture through the VSD is a neat and simple method, taking just 5 to 6 minutes to close a VSD. It can be repeated for the other VSDs without a great increase in cardiopulmonary bypass time, and we have created a maximum of 3 such sandwiches in a patient with a subsequent classic closure of the perimembranous VSD. On follow-up echocardiography, none of the patients operated on with this technique had residual shunts, which encourages us to continue using our simple technique.

We acknowledge the guidance of D. P. Shetty, MD, ex-Chief Cardiac Surgeon, B. M. Birla Heart Research Centre, Calcutta, India.

L. Kapoor MCh, DNB
M. D. Gan, MCh
M. B. Das, MCh
S. Mukhopadhyay, MCh
A. Bandhopadhyay, MCh
BM Birla Heart Research Centre
1/1 National Library Avenue
Calcutta 700 027, India

12/8/94231

References

1. Kitagawa T, Durham LA III, Mosca RS, Bove EL. Techniques and results in the management of multiple ventricular septal defects. J Thorac Cardiovasc Surg 1998;115:848-56. [Abstract/Free Full Text]
   
2. Brown JW. Discussion of Kitagawa et al.¹
   

This article has been cited by other articles:

				C. P. Brizard, C. Olsson, and J. L. Wilkinson New approach to multiple ventricular septal defect closure with intraoperative echocardiography and double patches sandwiching the septum J. Thorac. Cardiovasc. Surg., November 1, 2004; 128(5): 684 - 692. [Abstract] [Full Text] [PDF]

				M. Okubo, L. N. Benson, D. Nykanen, A. Azakie, G. Van Arsdell, J. Coles, and W. G. Williams Outcomes of intraoperative device closure of muscular ventricular septal defects Ann. Thorac. Surg., August 1, 2001; 72(2): 416 - 423. [Abstract] [Full Text] [PDF]

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