Introduction: Although multiple defects of the atrial septum are not uncommon, there remain limited data regarding the use of multiple devices in these patients. A variety of approaches to transcatheter closure have been used, and in this paper we describe the experience from two operators in a single centre. Methods: From September 2002 to September 2012, 673 transcatheter atrial septal defects (ASD) and patent foramen ovale (PFO) closure procedures were performed and retrospectively examined in a registry analysis. Results: Of these, 22 patients had multiple discrete defects, and four different approaches to closure were used. In 4 patients (18.2%) one device was used percutaneously to close multiple defects. Eleven patients (50%) had two devices inserted during the same procedure while two patients (9%) had two devices inserted as staged procedures. One patient (4.5%) had three devices inserted over two procedures. Four patients (18.2%) were found not to be suitable for percutaneous closure during the procedure and were referred for surgical closure. Conclusion: Our experience with the implant procedures, and clinical follow up of patients, shows that patients with multiple defects can be effectively treated with transcatheter device techniques including single device closure, multiple devices in one procedure and multiple devices in staged procedures and also with surgical repair.

with re-attachment to a single patch was widely employed in the earlier days 2 . Trusler introduced the two patch technique 3 and many subsequent investigators believed that this preserved atrioventricular valve (AV Valve) function better 4,5 . However, a careful review of different published series of repairs using one or two patch technique failed to document that one technique was superior to the other 6 . Wilcox and associates employed the technique of suturing the common atrioventricular valve to the ventricular septum to close the VSD and a patch to close the ASD. They excluded patients with a large ventricular component 7 . Nicholson and Nunn extended this simplified single patch technique to all sizes of the VSD 8 . They added a form of anterior "annuloplasty" during partitioning of the common AV valve. We are presenting our experience with this technique in fifteen consecutive infants. All sizes of VSD were included but annuloplasty was not performed. We found that this technique greatly simplified the repair of complete AVSD and was easily AbstractBackground: There has been a rekindling of interest in alternatives to conventional two patch technique for the repair of complete atrioventricular septal defect in infancy in the recent past. We applied the simplified single patch technique to 15 consecutive infants and herein report our intermediate term results. Methods: Between March 1998 and September 2001, fifteen patients underwent repair of complete atrioventricular septal defect with this technique (mean age 6 months, mean weight 5.4 kg). Downs syndrome was present in 11 patients. Repair was done in all patients by direct suturing of the common atrioventricular valve leaflets to the crest of the ventricular septum irrespective of the size of the ventricular septal component. The cleft in the anterior mitral leaflet was closed in all patients. The atrial septal component was closed by a pericardial patch.Results: There was no mortality. There were no pulmonary arterial hypertensive crises or heart block. The mean follow up was 13.2 months. One patient underwent mitral valve replacement after one year due to severe mitral regurgitation. The remaining fourteen patients had no significant mitral regurgitation, residual ventricular septal defect or left ventricular outflow tract obstruction on echocardiography.Conclusion: Simplified single patch technique is an easily reproducible method for surgical repair of complete atrioventricular septal defect. It is less time consuming and minimises ischaemic time. Atrioventricular valve function is preserved and there is no incidence of obstruction to left ventricular outflow tract. The intermediate term results are encouraging. (Ind J Thorac Cardiovasc Surg, 2003; 19: 102-107)

Background: The major strategy for palliation of cyanotic lesions in neonates is the systemic to pulmonary arterial shunt.Methods: Between May 1995, and December 2002, 48 consecutive neonates underwent systemic to pulmonary arterial shunts for cyanosis with reduced pulmonary blood flow. The mean age was 11.6 days (_+SD 7.38) and the mean weight, 3.2kg (+SD 0.52). The babies were classified into three groups: Group I -Tetralogy -pulmonary Atresia (n=18), Group II -Single Ventricle -Pulmonary atresia without (n=19) and with (n=5) isomerism, Group III-Pulmonary Atresia with Intact ventricular septum (n=6). Diagnosis was made by 2D echocardiography. Indication for cardiac catheterization was delineation of pulmonary anatomy / ductus laterality (n=4) or balloon atrial septostomy (n=4). The surgical procedure was a modified Blalock-Taussig shunt on the side of the situs. Post-operatively, no anti-coagulation or anti-platelet medication was employed.Results: There was no mortality. Four cases required revision of the shunt in the immediate post-operative period for shunt thrombosis. The mean follow up was 17.54 months (_+SD 8.36). In Group I, nine patients have undergone total correction with or without a conduit, while three required new arterial shunts for shunt/pulmonary artery stenosis. In Group II, nine patients have undergone bi-directional Glenn with atrial septectomy (n=2) and pulmonary artery plasty (n=4) and one patient underwent Fontan completion. In Group III, two patients underwent bi-directional Glenn and two had pulmonary valvotomy with/without right ventricular outflow tract widening. All the remaining babies are waiting for the second/final stage palliation or total correction.Conclusion: Systemic to pulmonary arterial shunts in neonates is a gratifying and reasonably safe surgical procedure. Most babies become candidates for eventual univentricular / bi-ventricular repair. (Ind J Thorac Cardiovasc Surg, 2003; 19: 159-162)

From May 1995 through October 2001, 19 infants less than 90 days old underwent surgical correction of total anomalous pulmonary venous connection. In 15 babies with isolated total anomalous pulmonary venous connection, there was one operative death. In 4 with complex anomalies, there were 2 operative deaths. The vertical vein was not ligated in 6 cases for various reasons. Two patients died during reoperation for early pulmonary venous obstruction. In the late follow-up, 2 babies required reoperation for late anastomotic stricture; one needed additional balloon dilatation. Of the 14 surviving patients, one had a small residual gradient and infrequent supraventricular tachycardia, the others were asymptomatic and without gradients. Surgical correction of total anomalous pulmonary venous connection can be carried out in early infancy with low mortality and morbidity. However, associated complex cardiac anomalies and small caliber pulmonary arteries and veins carry higher risks. Recurrent pulmonary venous obstruction and diffuse pulmonary vein stenosis are causes of early reoperation and poor surgical outcome.

A retrospective analysis of repair of aortic coarctation in young infants was conducted. Between April 1997 and December 2000, 21 patients under 4 months of age underwent repair of coarctation. Their mean age and weight were 41 42 days (range, 2 to 120 days) and 3.6 0.7 kg (range, 2.6 to 4.9 kg). The indications for surgery were congestive heart failure and/or shock. Diagnosis was made by 2-dimensional echocardiography with Doppler color flow imaging. Preoperative gradients ranged from 25 to 100 mm Hg. Aortic arch hypoplasia was present in 8 patients; 7 patients also had ventricular septal defect. Wide excision of the coarctation segment with extended end-to-end anastomosis was performed in 20 patients, while 1 required a Gore-Tex interposition graft between the left common carotid artery and the descending aorta. Subclavian angioplasty was performed to augment the anastomosis in 1 patient. There was no early mortality. One patient died 2 months after surgery. Follow-up examination revealed recoarctation in 5 patients (23.8%), all of whom underwent successful balloon dilatation. In conclusion, wider excision of the coarctation with extended end-to-end anastomosis reduces the chances of recoarctation. Percutaneous balloon angioplasty for treating recoarctation is effective in immediately reducing pressure gradients.