Historical Background
In terms of surgical closure of multiple defects in general, the landmark experience was reported by Kirklin and colleagues in 1980.1 They reported hospital mortality of 14%, and a need for reoperation to close residual defects in 28%. With regard to the Swiss-cheese septum, in an attempt hermetically to close all defects, and avoid a left ventriculotomy, Kitagawa and colleagues, in 1998, described the technique of using an oversized patch placed into the left ventricle via the right atrium.2 As an alternative, they also described the “sandwich technique”, achieved by transfixing the muscular edge of the defects to the anterior free wall of the ventricle after transecting the moderator band and right ventricular trabeculations to provide optimal exposure.2 Subsequent to this account, again with regard to the Swiss-cheese septum, Black and colleagues, in 2000, described closure of the defects using a single large autologous pericardial patch.3 Cetin and colleagues, in 2005, in contrast, used a composite patch of pericardium and Dacron graft. Both patches were placed using a right atrial approach.4Mace and colleagues then suggested placing several intermediate fixation stitches to prevent septal bulging.5 In 2001, Yamaguchi and associates had described a “felt sandwich technique”. This involved sandwiching the septum itself between two polyester felt patches placed in the left and right ventricles without need for ventriculotomy.6,7 Brizard and associates, in 2004, reported a similar technique using intraoperative echocardiography guidelines with excellent results.8 In 2006, Alsoufi and colleagues described transatrial re-endocardialization without dividing any trabeculations or the moderator band.9Much earlier, Stark and associates, in 1992, had closed the defects using a fibrin seal of human origin.10
At a much earlier date, Aaron and Lower, in 1975, had indicated that exposure and repair could be much easier when seemingly multipl defects were approached through the left ventricle.11 This was because, as we showed in our anatomical review, a solitary left ventricular opening was often viewed as multiple orifices seen from the right ventricular aspect. As we also explained in our first part, however, this variant is not the same as the Swiss-cheese septum. And. although this approach can facilitate the repair, debate has continued regarding its potential sequels of a left ventriculotomy. Surgical exposure through a left ventriculotomy can also, at times, be disappointing. With the problems of a left ventriculotomy in mind, therefore, others have advocated and demonstrated the safety and effectiveness of an apical right ventriculotomy.12-15Still others have proposed a two-staged approach, with an initial band placed on the pulmonary trunk, but this strategy has its own inherent morbidity and mortality.16,17
Transcatheter closure is now well recognized as an additional therapeutic option for closure of ventricular septal defects. The option was first reported by Lock and associates from Boston using the Rashkind devices.18 Then, in the late 1990s, a Nitinol device was added to the armamentarium of the interventionist.19-21 The interventional approach may be particularly suitable for multiple muscular septal defects located in the mid, apical, posterior, and anterior parts of the muscular septum.20-30 For most cardiac centers, however, devices delivered via catheters are not recommended in neonates and infants because of the need for a stiff guide wire. This can rupture the mitral valve, tear the septum, or invoke ventricular arrhythmias and cardiac arrest. In the new millennium, nonetheless, multiple groups have reported intraoperative perventricular closure, with encouraging early outcomes.22-28