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Ann Thorac Surg 1999;67:1754-1758
© 1999 The Society of Thoracic Surgeons

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Original Articles

"Swiss cheese" septal defects: surgical closure using a single patch with intermediate fixings

^a Department of Cardiovascular and Pediatric Cardiac Surgery, Marie Lannelongue Hospital, Paris-Sud University, Paris, France

Accepted for publication December 17, 1998.

Address reprint requests to Dr Macé, Département de Chirurgie Cardiovasculaire et Cardiaque Pédiatrique, Hôpital Marie Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis Robinson, France
e-mail: mace{at}ccml.com

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Residual ventricular septal defects and ventricular and septal dysfunctions are surgical drawbacks of "Swiss cheese" defects. We developed a technique that uses a single patch with intermediate fixings to cover the right side of the septum without producing a septal bulging, through a right atriotomy.

Methods. Since April 1993, 5 children with "Swiss cheese" defects have been operated on using this procedure (mean age, 17 ± 12 months). Three patients had associated lesions including tetralogy of Fallot, Taussig Bing heart, and mitral stenosis.

Results. There have been no early or late deaths. The mean follow-up time is 29 ± 18 months. All patients are asymptomatic. Echocardiography revealed either an intact septum (n = 4) or insignificant color jets at the apical portion of the septum (n = 1). The septal wall motion was preserved in 4 children and was hypokinetic in the fifth child.

Conclusions. This technique can be an additional tool to provide a secure closure of "Swiss cheese" defects even in the presence of associated cardiac lesions. Long-term consequences of this procedure on septal wall motion remain to be determined.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The most serious form of multiple ventricular septal defects (VSDs) are "Swiss cheese" defects. Complete repair of such defects remains associated with high morbidity and mortality. Major associated cardiac lesions add to the complexity of the repair [1, 2]. Improvements in repair of this challenging pathology were recently described to avoid the requirement of a right or left ventriculotomy [3–8]; they included VSD exposure by division of the moderator band [9], implantation of an oversized patch [10], application of biologic glue [11], and use of transcatheter [12–14] or intraoperative [15–18] device closure. Residual VSDs and postoperative myocardial dysfunction are still the cornerstones of the surgical results. To address these potential drawbacks, we closed "Swiss cheese" defects through an exclusive right atriotomy, using a large single patch with intermediate fixings, which prevent patch bulging, to cover the right side of the trabecular septum without septal division or ventricular incision.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Since April 1993, 5 consecutive children were referred to our institution for multiple VSDs and a "Swiss cheese" aspect of the trabecular septum. Three patients had major associated cardiac lesions. Three children had previously undergone a palliative procedure (Table 1). The classification of Soto and colleagues [19] is used to describe the VSDs. "Swiss cheese" defects are defined as the presence of uncountable VSDs in the trabecular septum. Diagnosis was established by color-coded echocardiography and angiocardiography (Fig 1) in each case [20]. It allowed us to determine the VSD sizes and locations and the characteristics of associated cardiac anomalies. The dominant VSD was either perimembranous (n = 2), midseptal trabecular (n = 1), inlet septal (n = 1), or subpulmonary (n = 1). In addition to these large VSDs, all children had separated uncountable VSDs, localized in one or more of the three portions of the trabecular septum—anterior, midseptal, or apical (Table 1). The pulmonary vascular bed was protected in 3 patients by naturally occuring (n = 1) or surgically created pulmonary stenosis (n = 2).

View larger version (79K): [in this window] [in a new window]   Fig 1. Preoperative left ventriculography angiocardiography of patient 5 (long axial oblique projection), with tetralogy of Fallot showing the "Swiss cheese" aspect of the trabecular septum. (A) Early in the injection, the midseptal trabecular ventricular septal defects are shown at end-systole. (B) Additional defects in the apical portion of the trabecular septum begin to opacify and are best seen, on a later frame, at end-diastole.

The trabecular septum was exposed through the tricuspid valve. With the preoperative location of the "Swiss cheese" VSDs in mind, the portion(s) of the trabecular septum to be covered by the single patch were delimited with several U-shaped mattress sutures of 4-0 polypropylene. These stay sutures were placed well beyond the theoretic border of all VSDs, taking one or more right-sided trabeculations superficially with the needle to avoid an intramural residual defect. To avoid a temporary shunting through the patch, a patch of double velour Dacron lined with preserved heterologous pericardium was trimmed to cover all portions of the trabecular septum with the anticipated presence of "Swiss cheese" defects. The patch fixation began at the distal portion of the defects and a continuous suture was used. Separate mattress sutures reinforced with pledgets were placed at several intermediate parts of the septum and passed into the patch to provide intermediate fixings, which allowed a close application of the patch onto the trabecular septum and avoided a bulge of the patch (Fig 2).

View larger version (29K): [in this window] [in a new window]   Fig 2. Single patch implantation extended to the apical portion of the trabecular septum. (A) The absence of intermediate fixings produces an aneurysmal effect. (B) With intermediate fixings, the patch is closely applied to the trabecular septum, thereby decreasing the tensile strength along the suture lines, without producing septal bulging. (LV = left ventricle; RV = right ventricle.)

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
All patients had successful closure of the "Swiss cheese" defects by that technique, covering one or more portions of the trabecular septum (Table 2). In 3 patients, additional pledget-supported sutures were necessary either in the apical (n = 1, patient 4) or anterior septum (n = 2, patients 2 and 3). The aortic cross-clamp time was 112 ± 13 minutes, due to the repair of associated cardiac lesions, but the procedure for closure of multiple VSDs was less than 40 minutes in each case. For patient 1, division of the moderator band [9], without division of the septal band, was done to expose the apical part of the trabecular septum. For patient 2, a single patch closed both the perimembranous and the midseptal VSDs. Tricuspid valve detachment, at the level of the medial papillary muscle, was done in this patient to improve the exposure. The tricuspid valve was repaired by reimplantation of chordae at their initial level using pledget-supported sutures. Additional procedures, except pulmonary artery debanding, were done in 3 patients (Table 2). A right ventriculotomy was necessary to repair the associated lesions in 2 patients but was not used to close the "Swiss cheese" VSDs.

Patients were followed up clinically and echocardiographically for a mean of 29 ± 18 months. There were no late deaths or reoperations. All patients were asymptomatic in sinus rhythm, without medication, except one who still received diuretic medication. Color-coded Doppler echocardiography found recovery of the global septal wall motion with persistent hypokinesis of the patched areas; normal right and left ventricular functions, except in patient 2, who had a decreased fractional shortening of the left ventricle (28%); and absence of any residual VSDs, except in patient 5, who had two insignificant residual Doppler color jets [21], less than 2 mm in diameter, that were seen on the right septal surface of the apical portion of the trabecular septum (Table 2).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Despite improved integrated treatment of multiple VSDs between operative and interventional techniques [9–14, 18], there is still significant concern regarding the optimal treatment of "Swiss cheese" VSDs. Patients with this defect still constitute a high-risk group, especially with the presence of major associated cardiac anomalies [1, 2]. Residual VSDs and postoperative myocardial dysfunction are related mainly to the uncertainty of the VSD location and the difficulty to obtain a complete closure without a right and/or left ventriculotomy.

Combined color-coded echocardiography and angiography have proved to be reliable means of obtaining an accurate preoperative diagnosis, but it remains difficult to ascertain whether all multiple trabecular VSDs are diagnosed, particularly when there is a nonrestrictive defect [20]. This uncertainty still exists intraoperatively because "Swiss cheese" VSDs are masked by numerous right-sided septal trabeculations. Clear exposure and localization of the VSDs could decrease the likelihood of a residual shunt. Unfortunately, division of right-sided septal trabeculations, and right or left ventriculotomies might be necessary to achieve this objective. In other words, the cost of excellent exposure and clear localization of the defects might be a high risk of myocardial and septal dysfunction.

The main advantage of a left ventriculotomy is that the VSDs’ left aspect is most often singular. Nevertheless, left ventricular incision and multiple patches or stitches impair septal wall motion and function, which contributes significantly to mortality and morbidity [9], including residual VSDs [4, 5], apical dyskinesia [3], and left ventricular dysfunction leading to heart transplantation or death [5]. Incisions confined to the left ventricle apex, as advocated recently [10], should avoid these long-term side effects because there is concensus that the left ventricle incision length should be as short as possible [6].

Recent improvements could decrease the rate of the aforementioned complications. Division of the moderator band [9] allows a clear exposure of the apical part of the trabecular septum. Oversized and sandwich patch techniques also seem to be useful tools [10]. Biologic glue was used in several patients with satisfactory results [11], although we chose not to use it because of the theoritic risk of embolization. Transcatheter device implantations seem to be useful to close high anterior or apical defects [12] and to simplify the final operative repair of associated cardiac defects [13, 14]; however, small residual defects could remain, even if not always hemodynamically significant. Moreover, devices must be placed intraoperatively in infants because of the size and stiffness of catheters [15–18].

In our patients, we closed the "Swiss cheese" VSDs, without residual VSDs and myocardial dysfunction, by using an exclusive right atrial approach. The main advantage of the single patch technique with intermediate fixings is that the exact location and number of VSDs do not need to be determined precisely because the patch covers the entire portion of the trabecular septum with the "Swiss cheese" VSDs. Therefore, a ventricular or septal incision is not necessary. There is experimental evidence that the location of the patch is essential to maintain normal relative volumes of ventricular chambers [22] and therefore respect each ventricular function as to the septation of Van Praagh type C single ventricle [23]. Thus, intermediate fixings of the patch is of major importance to avoid a septal bulge related to the pressure gradient between the two ventricles (Fig 2), which could produce a right ventricular outflow tract obstruction or a cavity acting as a left ventricular aneurysm, because these potential drawbacks are known to impair right ventricular function. Moreover, intermediate fixation decreases the tensile strength on the peripheral suture lines and the related risk of recurrent shunting. Finally, close application of the patch onto the septum avoids the necessity of a too-deep or transmural fixings, which could injure the coronary arteries, which is recognized as a pitfall of this procedure [6].

Anterior and apical defects do not need separate closure, because the patch can be extended to the right ventricle free wall, excluding a small part of the apex, as done in 2 of our patients, thereby resulting in a septation procedure because part of the apical portion of the right ventricle is in the left systemic position [12]. Nevertheless, very high anterior defects underneath the pulmonary valve, between the infundibular septum and the infundibular free wall, seem to require a separate surgical closure with pledget-supported sutures, as in patient 4, using either a small incision in the infundibular apical free wall or a transpulmonary approach. Alternatively, a preoperative transcatheter closure might be useful in such cases [12].

The remaining question concerns septal wall motion. Echocardiographic follow-up showed preserved septal wall function in 4 patients, although the areas covered by the patch were still hypokinetic. The interventricular septum, not involved by the insertion of the patch, remained sufficiently intact to preserve the global septal wall motion. In patient 2, hypokinetic global septal wall motion, with a decreased shortening fraction of the left ventricle, persisted through the most recent follow-up. There was no evidence that the left anterior descending artery was compromised by the repair, but the large patch, which involved both the perimembranous and trabecular septum, adversely affected the septal wall motion. Thus, in cases of major associated lesions, the dominant VSDs must be closed using a separate patch with this procedure.

Although it is now admitted that patients with multiple VSDs could undergo primary repair, "Swiss cheese" defects or multiple VSDs with associated cardiac lesions remain potential indications for delayed repair [1, 4, 10]. Pulmonary artery banding allows time for spontaneous or interventional closure of some of the defects and thus increases the likelihood of a simplified repair. Moreover, the absence of any growth potential of a large patch must be kept in mind, especially if it covers the three portions of the trabecular septum that resembles a Van Praagh type C single ventricle septation, and is another argument to defer complete repair when using our procedure. Shimazaki and coworkers [23] found that the size of the prosthetic septum should be as small as possible. In one of their patients, both ventricles developed satisfactorily despite the large septation patch [24]. At worst in our patients, the remaining portions of intact septum might grow and participate in the intrinsic septal contractility. Left ventricular dominance with a small right ventricle cavity, as well as a surgical repair in an infant under 4 kg, represent potential contraindications to this technique.

The single patch with intermediate fixings closure technique seems to be simple and reproducible, allowing for effective surgical repair even in complex forms of "Swiss cheese" VSDs with associated cardiac lesions. The procedure minimizes both the risk of residual VSDs and myocardial injury resulting in improved early outcome. Long-term consequences of this procedure remain to be assessed.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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