Introduction
As we discussed in our anatomical review, multiple ventricular septal defects are present when there are multiple channels within the muscular septum, for example producing the arrangement well described as the Swiss-cheese septum. This arrangement is different, however, from the situation in which a muscular defect co-exists with a defect located in the perimembranous region, or when there are multiple discrete defects within the muscular septum. These combinations, furthermore, differ from the arrangement in which a solitary defect within the muscular septum can seem to be multiple when it is viewed from the right ventricle, being crossed by apical trabeculations (Figure 1). The surgical strategy for closure of isolated defects, even if the defect itself is large, is now standardized. The management of multiple defects, however, remains nebulous, the more so since as we have shown the multiple defects themselves can be considered in terms of anatomic subsets. Our review has revealed the wide variations in practice between centers reporting their approach to these various sub-sets, with some of the approaches tailored specifically to one of the sub-sets. Because of this, it is difficult to determine the ideal operative approach. This is due, in part due to the paucity of comparative reports. It also reflects a lack of long-term follow-up. In this surgical part of our review, we assess the options available for potential management of each of the sub-sets identified subsequent to our anatomical analysis.