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.