Surgical management of muscular trabecular ventricular septal defects

Abstract

Despite recent advances in diagnosis, surgical techniques, and postoperative care of children with congenital cardiac defects, muscular trabecular ventricular septal defects (VSDs) are still a therapeutic challenge. Among these defects, it is more difficult to achieve secure and complete closure of low trabecular or apical VSDs because of the presence of numerous muscular trabeculations overlying the defect. When they are associated with "Swiss cheese"-type of VSDs, it is almost impossible to visualize the true edges of the defect through the transatrial approach. Consequently, there remains an unacceptable incidence of mortality and morbidity when compared to those that occur with closure of the usual perimembranous VSD. Although various techniques for closure of these difficult trabecular VSDs have been attempted, there is still a significant incidence of complications in the surgical management of trabecular VSDs, mostly significant residual shunts, a need for multiple reoperations, and severe left ventricular dysfunction. This article describes the anatomical details and classification of muscular trabecular VSDs. It also reviews several techniques currently utilized and their outcomes.

The heart exhibits right to left communication between the fibres of the muscular part of the interventricular septum

“…Venous bifurcation area of the central muscular part of the IVS was also concordant with the sphincter of the septal vessel (kuuselian vessel) [1]. The results were also concordant with a single muscular VSD of the left central muscular part of the IVS, with numerous sieve-like perforations through the right muscular part of the IVS formed from the medial wall of the foetal RV [2]. Agenesis of the sphincter of the septal vessel (kuuselian vessel) in the middle of the left IVS of the heart was the cause of the VSD.…”

“…A single VSD of the left central muscular part of the IVS may present with numerous sieve-like perforations through the right muscular part of the IVS formed from the medial wall of the foetal RV [2]. A small hole in the membranous part of the IVS becomes a hidden communication through the membranous part of the IVS as the aneurysm of the membranous part of the IVS grows over the hole on the right side after birth [10,13].…”

Multiple Ventricular Septal Defects: A New Strategy

“…The hospital mortality with conventional repair has been reported in the literature to be between 0 and 14.2% (1, 2, 4–21). In the 192 patients reported in the Congenital Database of the European Association of Cardio-Thoracic Surgery the hospital mortality was 8.5% 1 .…”

“…A palliative approach with conventional pulmonary artery banding (PAB) is a common surgical option, particularly in smaller infants and/or in the presence of associated anomalies, instead of primary repair (1, 2, 4–10, 15, 16, 18–21, 31). However the conventional PAB carries a high mortality.…”

“…The hospital mortality in the 739 patients reported in the Congenital Database of the European Association of Cardio-Thoracic Surgery (see text footnote 1) was 8.9%. In addition, indication for conventional PAB is limited by a series of drawbacks, particularly due to the difficulty in determining the optimal tightening with a stable and satisfactory balance between systemic and pulmonary circulation to promote adequate growth (1, 2, 4–10, 15, 16, 18–21, 30–37). …”