Ann Thorac Surg 1999;67:1758-1759
© 1999 The Society of Thoracic Surgeons
Commentaries
Edward L. Bove, MDa
a Division of Pediatric Cardiovascular Surgery, University of Michigan, F7830 Mott Children’s Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA
e-mail: elbove{at}umich.edu
Invited commentary
The management of the patient with multiple muscular ventricular septal defects (VSDs) remains controversial. The less than optimal results reported in most prior series result, in part, from the difficulties encountered in distinguishing the true margins of the VSDs from muscular trabeculations when viewed from the right ventricular side of the septum. We have reported the use of an oversized patch inserted through the tricuspid valve onto the left ventricular side of the septum as an effective method for secure closure of multiple VSDs (J Thorac Cardiovasc Surg 1998;115:848–56). This technique takes advantage of the higher pressure on the left side of the septum and requires relatively few sutures to anchor the patch into position. Thus, it becomes less important to know the precise number and location of the defects. Macé and associates propose another useful and innovative technique with excellent results. The authors have taken a right-sided approach placing a large, stiff patch with numerous "intermediate fixings" to avoid patch bulging and residual shunting. Although not reported in their series, the potential problems of "aneurysm" formation between the septum and the patch, tricuspid valve dysfunction, and residual intramural defects around the margins of the patch remain of concern. Although abnormalities of septal wall motion were present in all their patients after repair, no patient has significant residual shunting. An important advantage of this technique, similar to that of the left-sided approach, is that precise localization of the defects assumes lesser importance.
The authors question the utility of their approach in the younger patient, indicating that the absence of growth potential of the patch must be kept in mind. However, it is equally plausible that earlier, rather than later, repair may be preferable because the patch will progressively form a smaller amount of the septum, eventually reducing septal wall motion abnormalities. Additionally, younger patients have less right ventricular septal hypertrophy, which may make patch placement more secure. The optimal approach for the management of multiple VSDs in any institution will be determined by many factors, including patient age, VSD location, the presence of associated defects, and institutional surgical and interventional expertise. Surgical results are improving, and the addition of innovative techniques as outlined by the group from Marie Lannelongue promises to improve these outcomes for most patients.
