Skip to main content
SpringerLink
Log in

Techniques and results in the management of multiple muscular trabecular ventricular septal defects

  • Current Topics Review Article
  • Published:
General Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

The management of patients with multiple muscular trabecular ventricular septal defects (VSDs) remains controversial. In the past two decades, innovative techniques including a right ventricular apical infundibulotomy and transcatheter, intraoperative and perventricular device closure have been exploited, and essential right atrial approach and limited apical left ventriculotomy have also been refined. However, specific management guidelines for this difficult disease have not been established. In this article, the benefits and drawbacks of each technique are reviewed and discussed. Primary repair for infants with multiple muscular trabecular VSDs was associated with good late outcomes. The right atrial approach was satisfactory for all muscular VSDs, excluding apical defects that were well seen through a limited apical ventriculotomy. Surgical closure of apical defects could be achieved safely and completely in early infancy through a limited apical left ventriculotomy or a right ventricular apical infundibulotomy. Further follow-up and prudent evaluations of ventriculotomy-associated morbidities are needed. Pulmonary artery banding should be limited to a small infant with complex associated defects. Percutaneous device closure, the most desirable option, is impractical due to limitations between the delivery system and access route. Intraoperative device closure appears less successful than device closure in the catheterization laboratory. Perventricular device closure has a significant advantage of being a non-bypass procedure approach. A less invasive strategy for “true” Swiss cheese septum is needed. All may have an important role, and results obtained by using these techniques are encouraging. These hybrid approaches will promise future success on management guidelines of multiple muscular trabecular VSDs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Ludomirsky A, Huhta JC, Ill WV, Murphy DJ Jr, Danford DA, Morrow WR. Color Doppler detection of multiple ventricular septal defects. Circulation. 1986;74:1317–22.

    Article  PubMed  CAS  Google Scholar 

  2. Fellows KE, Westerman GR, Keane JF. Angiocardiography of multiple ventricular septal defects in infancy. Circulation. 1982;66:1094–9.

    Article  PubMed  CAS  Google Scholar 

  3. Kurokawa S, Taneoka M, Imai H, Baba H, Nomura M. Transesophageal echocardiography detection of undiagnosed multiple muscular ventricular septal defects with alteration of shunt flow by right ventricular pacing after an arterial switch operation in a neonate. Anesth Analg. 2011;113(2):233–5 (Epub 2011 May 19).

    Article  PubMed  Google Scholar 

  4. Breckenridge IM, Stark J, Waterston DJ, Bonham-Carter RE. Multiple ventricular septal defects. Ann Thorac Surg. 1972;13:128–36.

    Article  PubMed  CAS  Google Scholar 

  5. Fox KM, Patel RG, Graham GR. Multiple and single ventricular septal defect: a clinical and hemodynamic comparison. Br Heart J. 1978;40:141–6.

    Article  PubMed  CAS  Google Scholar 

  6. Hoffmeister HM, Fishbach H, Hoffmeister HE. Pulmonary arterial changes and hemodynamic parameters in isolated ventricular septal defect. J Thorac Cardiovasc Surg. 1981;29:355–8.

    Article  CAS  Google Scholar 

  7. Zuckerman WA, Richmond ME, Singh RK, Carroll SJ, Starc TJ, Addonizio LJ. Left-ventricular noncompaction in a pediatric population: predictors of survival. Pediatr Cardiol. 2011;32(4):406–12 (Epub 2010 Dec 25).

    Article  PubMed  Google Scholar 

  8. Sasaki Y, Ozawa T, Matsuura H, Saji T, Fujii T, Watanabe Y, Shiono N, Takanashi Y, Koyama N. Ventricular septal defect repair in an infant with severe pulmonary hypertension and preoperatively diagnosed left ventricular noncompaction. J Thorac Cardiovasc Surg. 2010;139(3):e31–3 (Epub 2009 Mar 26).

    Article  PubMed  Google Scholar 

  9. Ichida F. Left ventricular noncompaction. Circ J. 2009;73(1):19–26 (Epub 2008 Dec 4).

    Article  PubMed  CAS  Google Scholar 

  10. Kirklin JK, Castaneda AR, Keane JF, Fellows KE, Norwood WI. Surgical management of multiple ventricular septal defects. J Thorac Cardiovasc Surg. 1980;80:485–93.

    PubMed  CAS  Google Scholar 

  11. Soto B, Becker AE, Moulaert AJ, Lie JT, Anderson RJ. Classification of ventricular septal defects. Br Heart J. 1980;43:332–43.

    Article  PubMed  CAS  Google Scholar 

  12. Jacobs JP, Burke RP, Quintessenza JA, Mavroudis C. Congenital heart surgery nomenclature and database project: ventricular septal defect. Ann Thorac Surg. 2000;69:S25–35.

    Article  PubMed  CAS  Google Scholar 

  13. Van Praagh S, Mayer JE Jr, Berman NB, Flanagan MF, Geva T, Van Praagh R. Apical ventricular septal defects: follow-up concerning anatomic and surgical considerations. Ann Thorac Surg. 2002;73(1):48–56 (discussion 56–7).

    Article  PubMed  Google Scholar 

  14. Serraf A, Lacour-Gayet F, Bruniaux J, et al. Surgical management of isolated ventricular septal defects: logical approach in 130 cases. J Thorac Cardiovasc Surg. 1992;103:437–43.

    PubMed  CAS  Google Scholar 

  15. Kitagawa T, Durham LA 3rd, Mosca RS, Bove EL. Techniques and results in the management of multiple ventricular septal defects. J Thorac Cardiovasc Surg. 1998;115(4):848–56.

    Article  PubMed  CAS  Google Scholar 

  16. Seddio F, Reddy VM, MaElhinney DB, Tworetzky W, Silverman NH, Hanley FL. Multiple ventricular septal defects: how and when should they be repaired? J Thorac Cardiovasc Surg. 1999;117(1):134–40.

    Article  PubMed  CAS  Google Scholar 

  17. Macé L, Dervanian P, Le Bret E, Folliguet TA, Lambert V, Losay J, Neveux JY. “Swiss cheese” septal defects: surgical closure using a single patch with intermediate fixings. Ann Thorac Surg. 1999;67(6):1754–8 (discussion 1758-9).

    Article  PubMed  Google Scholar 

  18. Black MD, Shukla V, Rao V, Smallhorn JF, Freedom RM. Repair of isolated multiple muscular ventricular septal defects: the septal obliteration technique. Ann Thorac Surg. 2000;70:106–10.

    Article  PubMed  CAS  Google Scholar 

  19. Cetin G, Ozkara A, Akcevin A, Korkut AK, Soyler I, Koner O, Tireli E. Repair of multiple muscular ventricular septal defects: septal obliteration technique. J Card Surg. 2005;20(3):274–7.

    Article  PubMed  Google Scholar 

  20. Alsoufi B, Karamlou T, Osaki M, Badiwala MV, Ching CC, Dipchand A, McCrindle BW, Coles JG, Caldarone CA, Williams WG, Van Arsdell GS. Surgical repair of multiple muscular ventricular septal defects: the role of re-endocardialization strategy. J Thorac Cardiovasc Surg. 2006;132(5):1072–80.

    Article  PubMed  Google Scholar 

  21. Sivakumar K, Anil SR, Rao SG, Shivaprakash K, Kumar RK. Closure of muscular ventricular septal defects guided by en face reconstruction and pictorial representation. Ann Thorac Surg. 2003;76(1):158–66.

    Article  PubMed  Google Scholar 

  22. Castaneda AR, Jonas RA, Mayer JE, Hanley FL. Cardiac surgery of the neonate and infant. Philadelphia: WB Saunders; 1994. p. 187–201.

  23. Hanna B, Colan SD, Bridges ND, Mayer JD, Castaneda AR. Clinical and myocardial status after left ventriculotomy for ventricular septal defect closure [abstract]. J Am Coll Cardiol. 1991;17(suppl):110A.

    Article  Google Scholar 

  24. Lanford LM, Vermilion RP, Shulkin BL, Bove EL. Left ventricular function following apical ventriculotomy for closure of muscular ventricular septal defects [abstract]. J Am Coll Cardiol. 1996;27:343A.

    Article  Google Scholar 

  25. Rizzoli G, Rubino M, Mazzucco A, Rocco F, Brumana T, Scutari M, et al. Progress in the surgical treatment of ventricular septal defect: an analysis of twelve years’ experience. J Thorac Cardiovasc Surg. 1983;31:382–8.

    Article  CAS  Google Scholar 

  26. Friedman WF, Mehrizi A, Pusch AL. Multiple muscular ventricular septal defects. Circulation. 1965;32:35–42.

    Article  PubMed  CAS  Google Scholar 

  27. Zavanella C, Matsuda H, Jara F, Subramanian S. Left ventricular approach to multiple ventricular septal defects. Ann Thorac Surg. 1977;24:537–43.

    Article  PubMed  CAS  Google Scholar 

  28. McDaniel N, Gutsell HP, Nolan SP, Kron IL. Repair of large muscular ventricular septal defects in infants employing left ventriculotomy. Ann Thorac Surg. 1989;47:593–4.

    Article  PubMed  CAS  Google Scholar 

  29. Waldhausen JA, Herendeen T, Taybi H. Left ventriculotomy: effects on ventricular function and coronary vessels. Surgery. 1964;56:868–73.

    PubMed  CAS  Google Scholar 

  30. Replogle RL, Kundler H, Gross RE. Left ventricular performance following apical left ventriculotomy. Arch Surg. 1967;95:892–7.

    Article  PubMed  CAS  Google Scholar 

  31. Aaron BL, Lower RR. Muscular ventricular septal defect repair made easy. Ann Thorac Surg. 1975;19:568–70.

    Article  PubMed  CAS  Google Scholar 

  32. Singh AK, DeLeval MR, Stark J. Left ventriculotomy for closure of muscular ventricular septal defects: treatment of choice. Ann Surg. 1977;186:577–80.

    Article  PubMed  CAS  Google Scholar 

  33. Griffiths SP, Turi GK, Ellis K, et al. Muscular ventricular septal defects repaired with left ventriculotomy. Am J Cardiol. 1981;48:877–86.

    Article  PubMed  CAS  Google Scholar 

  34. Barbero-Marcial M, Riso A, De Albuquerque AT, Atik E, Jatene A. Left ventricular apical approach for the surgical treatment of congenital mitral stenosis. J Thorac Cardiovasc Surg. 1993;106(1):105–10.

    PubMed  CAS  Google Scholar 

  35. Prêtre R, Benedikt P, Turina MI. Modified approach to close multiple apical ventricular septal defects. Eur J Cardiothorac Surg. 1999;16(6):683–5.

    Article  PubMed  Google Scholar 

  36. Shin HJ, Jhang WK, Park JJ, Yu JJ, Kim YH, Ko JK, Park IS, Seo DM. Left ventricular function after left ventriculotomy for surgical treatment of multiple muscular ventricular septal defects. Ann Thorac Surg. 2011;92(4):1490–3 (Epub 2011 Aug 12).

    Article  PubMed  Google Scholar 

  37. Kumar K, Lock JE, Geva T. Apical muscular ventricular septal defects between the left ventricle and the right ventricular infundibulum. Diagnostic and interventional considerations. Circulation. 1997;95(5):1207–13.

    Article  PubMed  CAS  Google Scholar 

  38. Stellin G, Padalino M, Milanesi O, Rubino M, Casarotto D, Van Praagh R, Van Praagh S. Surgical closure of apical ventricular septal defects through a right ventricular apical infundibulotomy. Ann Thorac Surg. 2000;69(2):597–601.

    Article  PubMed  CAS  Google Scholar 

  39. Padalino MA, Stellin G, Testolin L, Neirotti RA. Surgical treatment of apical muscular ventricular septal defects. Eur J Cardiothorac Surg. 2000;18(4):500–1.

    Article  PubMed  CAS  Google Scholar 

  40. Tsang VT, Hsia TY, Yates RW, Anderson RH. Surgical repair of supposedly multiple defects within the apical part of the muscular ventricular septum. Ann Thorac Surg. 2002;73(1):58–62 (discussion 62–3).

    Article  PubMed  Google Scholar 

  41. Myhre U, Duncan BW, Mee RB, Joshi R, Seshadri SG, Herrera-Verdugo O, Rosenthal GL. Apical right ventriculotomy for closure of apical ventricular septal defects. Ann Thorac Surg. 2004;78(1):204–8.

    Article  PubMed  Google Scholar 

  42. Geva T, Powell AJ, Crawford EC, Chung T, Colan SD. Evaluation of regional differences in right ventricular systolic function by acoustic quantification echocardiography and cine magnetic resonance imaging. Circulation. 1998;98:339–45.

    Article  PubMed  CAS  Google Scholar 

  43. Lock JE, Block PC, McKay RG, Baim DS, Keane JF. Transcatheter closure of ventricular septal defects. Circulation. 1988;78(2):361–8.

    Article  PubMed  CAS  Google Scholar 

  44. Bridges N, Perry SB, Keane JF, et al. Preoperative transcatheter closure of congenital muscular ventricular septal defects. N Engl J Med. 1991;324:1312–7.

    Article  PubMed  CAS  Google Scholar 

  45. Butera G, Carminati M, Chessa M, Piazza L, Abella R, Negura DG, Giamberti A, Claudio B, Micheletti A, Tammam Y, Frigiola A. Percutaneous closure of ventricular septal defects in children aged <12: early and mid-term results. Eur Heart J. 2006;27(23):2889–95 (Epub 2006 Oct 19).

    Article  PubMed  Google Scholar 

  46. Lim DS, Forbes TJ, Rothman A, Lock JE, Landzberg MJ. Transcatheter closure of high-risk muscular ventricular septal defects with the CardioSEAL occluder: initial report from the CardioSEAL VSD registry. Catheter Cardiovasc Interv. 2007;70(5):740–4.

    Article  PubMed  Google Scholar 

  47. Carminati M, Butera G, Chessa M, De Giovanni J, Fisher G, Gewillig M, Peuster M, Piechaud JF, Santoro G, Sievert H, Spadoni I, Walsh K, Investigators of the European VSD Registry. Transcatheter closure of congenital ventricular septal defects: results of the European Registry. Eur Heart J. 2007;28(19):2361–8 (Epub 2007 Aug 7).

    Article  PubMed  Google Scholar 

  48. El Tahlawi M, Kammache I, Fraisse A. Ventricular septal defect closure in small children with the Amplatzer Duct Occluder II. Catheter Cardiovasc Interv. 2011;77(2):268–71.

    Article  PubMed  Google Scholar 

  49. Fishberger SB, Bridges ND, Keane JF, Hanley FH, Jonas RA, Mayer JE, et al. Intraoperative device closure of ventricular septal defects. Circulation. 1993;88:205–9.

    Google Scholar 

  50. Kapoor L, Gan MD, Das MB, Mukhopadhyay S, Bandhopadhyay A. Technique to repair multiple muscular ventricular septal defects. J Thorac Cardiovasc Surg. 1999;117(2):402–3.

    Article  PubMed  CAS  Google Scholar 

  51. Ootaki Y, Yamaguchi M, Yoshimura N, Oka S, Yoshida M, Hasegawa T. Surgical management of trabecular ventricular septal defects: the sandwich technique. J Thorac Cardiovasc Surg. 2003;125(3):508–12.

    Article  PubMed  Google Scholar 

  52. Murakami H, Yoshimura N, Takahashi H, Matsuhisa H, Yoshida M, Oshima Y, Misaki T, Yamaguchi M. Closure of multiple ventricular septal defects by the felt sandwich technique: further analysis of 36 patients. J Thorac Cardiovasc Surg. 2006;132(2):278–82.

    Article  PubMed  Google Scholar 

  53. Yoshimura N, Matsuhisa H, Otaka S, Kitahara J, Murakami H, Uese K, Ichida F, Misaki T. Surgical management of multiple ventricular septal defects: the role of the felt sandwich technique. J Thorac Cardiovasc Surg. 2009;137(4):924–8 Epub 2008 Dec 19.

    Article  PubMed  Google Scholar 

  54. Bacha EA, Cao QL, Starr JP, Waight D, Ebeid MR, Hijazi ZM. Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results. J Thorac Cardiovasc Surg. 2003;126(6):1718–23.

    Article  PubMed  Google Scholar 

  55. Brizard CP, Olsson C, Wilkinson JL. New approach to multiple ventricular septal defect closure with intraoperative echocardiography and double patches sandwiching the septum. J Thorac Cardiovasc Surg. 2004;128(5):684–92.

    PubMed  Google Scholar 

  56. Becker P, Frangini P, Heusser F, Urcelay G, Garay F. New surgical approach to device closure of multiple apical ventricular septal defects. Rev Esp Cardiol. 2004;57(12):1238–40.

    PubMed  Google Scholar 

  57. Bacha EA, Cao QL, Galantowicz ME, Cheatham JP, Fleishman CE, Weinstein SW, Becker PA, Hill SL, Koenig P, Alboliras E, Abdulla R, Starr JP, Hijazi ZM. Multicenter experience with perventricular device closure of muscular ventricular septal defects. Pediatr Cardiol. 2005;26(2):169–75.

    Article  PubMed  CAS  Google Scholar 

  58. Crossland DS, Wilkinson JL, Cochrane AD, d’Udekem Y, Brizard CP, Lane GK. Initial results of primary device closure of large muscular ventricular septal defects in early infancy using perventricular access. Catheter Cardiovasc Interv. 2008;72(3):386–91.

    Article  PubMed  CAS  Google Scholar 

  59. Amin Z, Danford DA, Lof J, Duncan KF, Froemming S. Intraoperative device closure of perimembranous ventricular septal defects without cardiopulmonary bypass: preliminary results with the perventricular technique. J Thorac Cardiovasc Surg. 2004;127(1):234–41.

    Article  PubMed  Google Scholar 

  60. Bacha EA, Hijazi ZM, Cao QL, Abdulla R, Starr JP, Quinones J, Koenig P, Agarwala B. Hybrid pediatric cardiac surgery. Pediatr Cardiol. 2005;26(4):315–22.

    Article  PubMed  CAS  Google Scholar 

  61. Kozlik-Feldmann R, Lang N, Aumann R, Lehner A, Rassoulian D, Sodian R, Schmitz C, Hinterseer M, Hinkel R, Thein E, Freudenthal F, Vasilyev NV, del Nido PJ, Netz H. Patch closure of muscular ventricular septal defects with a new hybrid therapy in a pig model. J Am Coll Cardiol. 2008;51(16):1597–603.

    Article  PubMed  Google Scholar 

  62. Diab KA, Cao QL, Mora BN, Hijazi ZM. Device closure of muscular ventricular septal defects in infants less than one year of age using the Amplatzer devices: feasibility and outcome. Catheter Cardiovasc Interv. 2007;70(1):90–7.

    Article  PubMed  Google Scholar 

  63. Neukamm C, Bjørnstad PG, Fischer G, Smevik B, Lindberg HL. A novel method of hybrid intraoperative catheter-based closure of ventricular septal defects using the Amplatzer® PDA occluder. Catheter Cardiovasc Interv. 2011;77(4):557–63.

    Article  PubMed  Google Scholar 

  64. Zhu D, Liu B, Lin K. Successful repair of multiple muscular ventricular septal defects using a unique hybrid procedure. J Card Surg. 2011;26(2):237–9 Epub 2011 Jan 31.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiovascular Surgery, Institute of Health Biosciences, The University of Tokushima Graduate School, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan

    Tetsuya Kitagawa, Takashi Kitaichi, Mikio Sugano & Hirotsugu Kurobe

Authors
  1. Tetsuya Kitagawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Takashi Kitaichi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mikio Sugano
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hirotsugu Kurobe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tetsuya Kitagawa.

Additional information

The review was submitted at the invitation of the editorial committee.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kitagawa, T., Kitaichi, T., Sugano, M. et al. Techniques and results in the management of multiple muscular trabecular ventricular septal defects. Gen Thorac Cardiovasc Surg 61, 367–375 (2013). https://doi.org/10.1007/s11748-013-0267-8

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11748-013-0267-8

Keywords

Search

Navigation