Intraoperative location of muscular ventricular septal defects

Abstract

We would like to congratulate Dr Black and colleagues on their recent article [1Black M.D. Shukla V. Rao V. Smallhorn J.F. Freedom R.M. Repair of isolated multiple muscular ventricular septal defects the septal obliteration technique.Ann Thorac Surg. 2000; 70: 106-110Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. The article addressed the difficult issues of intraoperative location of muscular ventricular septal defects (VSDs) and their surgical closure. In 4 patients they highlighted the use of a cardioscope to either transilluminate (n = 2) or pass a silk suture through the muscular VSD (n = 2). In our practice, we have also developed a novel method of finding muscular VSD intraoperatively using transillumination. Between December 1999 and August 2000, 4 patients (mean age, 22 months; range, 4–60 months; and weight, 8.3 kg; range, 5–12.9 kg) with multiple VSDs presented for elective closure. These patients all had a perimembraneous (n = 2) or subaortic (n = 2) VSD as well as a muscular VSD. One patient had previous pulmonary artery banding. All patients were placed on cardiopulmonary bypass with bicaval cannulation to ascending aortic return. Cold blood cardioplegia and topical slush was used to arrest and protect the heart. A right atriotomy was performed and the left heart vented through the foramen ovale. A sterile long, thin, flexible anaesthetic oro-tracheal light source (Surch-Lite, Aaron, St. Petersburg, FL) (Fig 1) was passed through the subaortic VSD (2 of 4) or perimembraneous VSD (2 of 4), and guided into the left ventricle by manipulation. Through the tricuspid valve, the ventricular septum is visualized and muscular VSDs are seen as regions of light. Repair of the muscular VSD was done with a bovine patch in 3 out of 4 patients, and plegetted sutures in 1 out of 4 patients. The perimembraneous or subaortic VSD was repaired in the normal manner with a Dacron (Bard, Tempe, AZ) patched using continuous suture technique. The transillumination is repeated until all VSDs have been satisfactorily identified. The competency of the ventricular septum is then conformed by filling the left ventricle with saline at the end of the procedure. All patients survived and there were no complications from the use of this technique. No significant residual VSD was detected on postoperative echocardiography in any of the patients. This new technique has several advantages. The light source is cheap, disposable, and easily available. Its flexibility ensures that insertion is simple and can be directed to transilluminate all areas of the septum. Even though it is guided by touch, potential injury to the heart is minimized because it has no sharp edges and follows the normal flow of blood. Because the light source passes through the foramen ovale or perimembraneous VSDs, there is no need for a separate aortotomy to be performed, which has the potential risk of injury to the aorta or the aortic valve. In addition, the light source is small enough to be used even in neonates where a cardioscope would be too large. Thus we believe this is a useful and safe technique that has much to commend it. Intraoperative location of muscular ventricular septal defects: ReplyThe Annals of Thoracic SurgeryVol. 72Issue 5Preview Full-Text PDF