Management of multiple ventricular septal defects: Evolution of surgical technique

Abstract

Background Residual ventricular septal defects (VSDs), ventricular and septal dysfunction and heart block are frequent complications in surgical management of multiple VSDs (Swiss cheese heart). The technique with the lowest risk of morbidity and mortality has still to be identified. Methods Between January 200 and September 2012, 45 patients with a median age of 4.1 years (2 months to 15 years) underwent surgical closure of multiple VSDs. In 22 cases there were associated lesions. Two-stage repair, i.e. pulmonary artery banding (PAB) followed by VSDs closure using different techniques, was adopted in 29 cases (group A). Primary repair was performed in 15 cases (group B). Six out of these 15 cases were managed by the so-called sandwich technique (group B1), whereas in the other nine other techniques of closure were used (group B2). Results The overall mortality was 8.9% (4/45). Three of the four deaths occurred in group A and one in group B2. Follow-up of group A showed that 26 patients had residual VSDs (2 of whom needing early redo surgery), 2 patients had left ventricular dysfunction and one patient developed heart block. In group B1, there were five cases with residual VSDs. In group B2, there were five cases with residual VSDs (only one needing redo surgery), one case with left ventricular dysfunction and one case with heart block. Conclusion Primary repair of multiple VSDs is associated with less morbidity and mortality than staged repair. The sandwich technique has the lowest risk of residual VSDs, septal dysfunction and heart block compared to the other techniques. However, particular attention is needed in positioning the left-sided patch to avoid septal bulging with consequent left ventricular outflow tract obstruction and interference with mitral valve chordae with secondary mitral regurgitation.