<div>Title:</div><div>Better outcomes depend on surgeons joining cardiologists.</div><div>Authors</div><div>Leonardo Mulinari</div><div>(Corresponding Author)</div><div>University of Miami Miller School of Medicine, Surgery</div><div>1611 NW 12th Ave</div><div>East Tower Suite 3016A</div><div>Miami, FL, USA 33136-1015</div><div>l.mulinari@med.miami.edu</div><div>Luciana da Fonseca da Silva</div><div>Children’s Hospital of Pittsburgh of UPMC, Cardiothoracic Surgery</div><div>4401 Penn Avenue</div><div>5th Floor Faculty Pavilion</div><div>Pittsburgh, PA, USA 15224</div><div>4125234078</div><div>dafonsecadasilval@upmc.edu</div><div>Data sharing is not applicable to this article as no new data were
created or analyzed in this study.</div><div>Funding: none</div><div>Conflict of interest: none</div><div>Hybrid approaches are being used for aortic stent implantation,
pulmonary valve implants, intraoperative stent implantation, and
perventricular ventricular septal defects closure.11Agrawal H,
Alkashkarib W, Kennyc D. Evolution of hybrid interventions for
congenital heart disease. Expert Review of Cardiovascular Therapy,
15:4, 257-266, DOI: 10.1080/14779072.2017.1307733</div><div>Closure of apical ventricular septal defects in infants is challenging
for surgeons and interventional cardiologists. Although a hybrid
approach has been used for some
time, Changwe et al22Changwe
GJ, Hongxin L, Zhang HZ, et al. Percardiac closure of large apical
ventricular septal defects
in infants: novel modifications and mid-term results. <i>Journal of
Cardiac Surgery in press</i>  describe a novel surgical technique to
close apical ventricular septal defects that uses a probe-assisted
delivery system. This is done through a chest incision with the aid of
transesophageal echocardiography.</div><div>Trans-catheter repair of apical interventricular septal defects (VSDs)
has been expanded to different defect types since its introduction into
clinical practice. Continuous improvements in occlusion devices and
sheaths have occurred. Vascular and bodyweight limitations, as well as
associated complications, led to the conception of percardiac device
closure techniques, especially for apical muscular VSDs.33Amin
Z, Gu X, Berry JM, Titus JL, Gidding SS and Rocchini AP.
Periventricular closure of ventricular septal defects without
cardiopulmonary bypass. Ann Thorac Surg 1999; 68:149-53.</div><div>This retrospective report by Changwe et al. reviews their clinical
experience since 2011 with 36 infants undergoing perventricular or
peratrial device closure of apical muscular VSDs. They divided the
population into three groups according to the access pathway applied.
They detail the advantages and limitations of the surgical technique in
each group, and report different locations and configurations of
muscular VSDs (Cylindrical, Tunnel, Cave-like, Multiple holed) that can
interfere with the surgical approach. The peratrial approach was more
aesthetical, less traumatic and painful, preserved RV wall intact, and
had a shorter length of hospital stay. However, the acute angle formed
by the peratrial route for VSD closure precludes its use in some
circumstances. Therefore, perventricular was the route was of choice for
complex VSD types (tortuous tunnel-shaped, cave-like, multiple) and the
anterior apical location. They showed that the perventricular pathway
was suitable for the occlusion of all types of apical VSDs.</div><div>There are limitations to this retrospective analysis when comparing the
three groups, mainly due to the morphological complexity of the defects.
The authors did not explain which criteria they used to choose the
access route in the different types and locations of the defects.
Increased success rate, without immediate complications, without the use
of Xray, small residual VSD percentage, with clinical improvement in
this challenging group of patients, reinforces the superiority of the
percardiac approach.</div><div>This approach provides an excellent alternative in the treatment of
patients with muscular VSDs. Long-term outcomes were excellent, and
morbidity associated with cardiopulmonary bypass and conventional
surgical repair was avoided. 44Kang SL, Tometzki A, Caputo M,
Morgan G, Parry A, Martin R. Longer-term outcome of perventricular
device closure of muscular ventricular septal defects in children.
Catheter Cardiovasc Interv. 2015 May;85(6):998-1005. doi:
10.1002/ccd.25821. Epub 2015 Feb 3. PMID: 25573696.</div><div>Patients with apical muscular VSD are challenging and the collaborative
approach between surgeons and interventional cardiologists seems to be
the best approach for better care.</div>