Biventricular surgical repair of “Swiss Cheese” ventricular septal defects with two-patch and right ventricle apex excluding technique: preliminary experience and clinical results

Abstract

Background “Swiss Cheese” ventricular septal defects (VSDs) is a kind of rare and complex congenital heart defects and the surgical management remains controversial and a challenge. We reviewed our preliminary clinical experience on biventricular surgical repair of “Swiss Cheese” VSDs with two-patch and right ventricle apex excluding technique in 10 cases. Methods From May 2014 to December 2019, a series of 10 patients (M/F=3/7) were admitted in our center. 9 cases underwent one-stage surgical repair with two-patch and right ventricle apex excluding technique and 1 case received a second-stage surgical repair with the same technique. Surgical repair was done with cardiopulmonary bypass (CPB) in all cases. 2 fresh autologous pericardium patches were used to close defects of the outflow tract area and the apex trabecular area respectively and as a result, the right ventricular apex was excluded from the right ventricular inflow tract. Results All the operations were successful. Median CPB time and aortic clamping time were 96 min and 68 min respectively. Delayed chest closure were done in 2 cases within 48-72 hours postoperatively. The Median time of mechanical ventilation and ICU stay were 131.3 hours and 8 days respectively. Median length of stay after operation was 11 （9-42）days. There was no mortality and major complication except for 2 cases of ventilator associated pneumonia. There was no death and major complication during the median follow-up time of 3.2 years.. The latest echocardiography results showed the left and right heart function was normal in all the cases. Conclusions Biventricular surgical repair of “Swiss Cheese” VSDs with two-patch of fresh autologous pericardium and right ventricle apex excluding technique in infants is safe and feasible with favorable early and mid-term results. Long term results need to be evaluated with more cases.

A review of the therapeutic management of multiple ventricular septal defects

“…Two patches of bovine pericardium were used to close the defects, excluding the apex of the right ventricle (Figure 12). 62 The first bovine pericardial patch was sutured at the upper edge of the deficient septum and moderator band using a 6-0 polypropylene suture. A second pericardial patch was used to close the defects present between the moderator band and the anterior free wall of the right ventricle.…”

“…This protocol has also been employed in cases of multiple septal defects having anatomical peculiarities predisposing to postoperative heart block, and residual defects in a small infant. 14,16,17,43 Two-patch and right ventricle apex exclusion technique: Perez-Negueruela et al 50 and Wu et al 62 developed this technique of closing either multiple large apical muscular or the Swiss-cheese septum using a procedure that involved the exclusion of the right ventricular apex through the tricuspid route. Associated septal defects were closed separately.…”

A Review of the Therapeutic Management of Multiple Ventricular Septal Defects

“…Associated septal defects were closed separately. 50,62 A 10-Fr Foley catheter was railroaded through a defect to facilitate visualization of the overall arrangement by applying gentle traction. Two patches of bovine pericardium were used to close the defects, excluding the apex of the right ventricle (Figure 12).…”

“…Two patches of bovine pericardium were used to close the defects, excluding the apex of the right ventricle (Figure 12). 62 The first bovine pericardial patch was sutured at the upper edge of the deficient septum and moderator band using a 6-0 polypropylene suture. A second pericardial patch was used to close the defects present between the moderator band and anterior free wall of the right ventricle.…”

“…Some investigators have used a 5-0 polypropylene purse string suture to exclude the apical portion of the right ventricle, thereby occluding multiple defects between the trabeculations of the right ventricle. 50,62 Repair of the Swiss-cheese septum using biologic glue In 1992, Stark and associates developed this technique using fibrin seal of human origin (Tissucal, Immuno-France, Orly, France). Fibrin seal consists of concentrated lyophilized fibrinogen enriched with factor XIII and fibronectin.…”