Intraoperative customized double-patch device with twin sutures for multiple muscular septal defects.

OBJECTIVES: Closure of multiple muscular ventricular septal defects (VSDs) remains a challenge because of anatomical complexity. METHODS: We mapped all the VSDs using en face reconstruction of the right ventricular septal surface through echocardiography and then performed an 'Intraoperative Customized Double-Patch Device' technique to surgically close them in 39 patients (male:female = 25:14). The median age of the patients was 6 months (2 months-10 years), and mean weight was 5.98 ± 4.21 kg. A patch of polytetrafluoroethylene was placed on the left ventricular side of the defect and another on the right ventricular side, and they were anchored to each other using 2 polypropylene sutures. Residual shunts were evaluated using intraoperative echocardiography and measurements of right atrial-pulmonary arterial saturation were taken in all patients. RESULTS: The distribution of muscular VSDs was as follows: anterior muscular 12, posterior muscular 18, mid-muscular 11 and apical 9. The associated lesions included perimembranous VSD (n = 28), tetralogy of Fallot (n = 6), double-outlet right ventricle (n = 2) and supramitral membrane (n = 2). Mean clamp time and bypass time were 93 ± 19 min and 147 ± 26 min, respectively. Mean hospital stay was 11 ± 3.39 days with no in-hospital mortality. Five patients with significant residual shunts needed concomitant PA banding. All patients remained in New York Heart Association Class I. There was either no residual shunt (n = 3) or trivial shunt (n = 2) among the banded patients. All patients remained symptom-free and continued to thrive well at the most recent follow-up (3.48 ± 1.51 years). CONCLUSIONS: Muscular VSDs can be mapped through en face reconstruction and closed using intraoperative customized double-patch device technique in a variety of situations with satisfactory immediate and short-term results.

Transposition of the Great Arteries With Total Anomalous Pulmonary Venous Connection.

Transposition of the great arteries (TGA) with total anomalous pulmonary venous connection (TAPVC) is a rare association. Very few such cases have been reported. Among them 1 patient underwent anatomic repair. The rest received repair at the atrial level with either a modified Senning technique or a Mustard technique. We report a rare combination of TGA, TAPVC draining to the coronary sinus, and left juxtaposition of the atrial appendages with a diminutive right atrium. The anomalies were successfully repaired by anatomic correction.

Right Posterior Thoracotomy for Open-Heart Surgery in a Rare Morphology.

The closure of atrial septal defects through right-sided limited posterior thoracotomy has been well established in selected subsets. We present a case of large ostium secundum atrial septal defect, pulmonary valvar stenosis, absent right superior vena cava, and isolated left superior vena cava draining to right atrium via coronary sinus. The child successfully underwent total correction through limited posterior thoracotomy with necessary modifications of intraoperative steps.

An unusual fenestration in single-stage Fontan operation.

Fontan operation and importance of fenestration in the treatment of unusual and complex forms of double outlet right ventricle (DORV) are well established. Nonetheless, rarely, the creation of fenestration becomes challenging in complex morphologies. We present one such child with situs solitus, dextrocardia, DORV, hypoplastic right ventricle, large ventricular septal defect, severe pulmonic stenosis, extremely small right atrium and left juxtaposed atrial appendages, who underwent Fontan operation. We created an unusual fenestration between left pulmonary artery and juxtaposed right atrial appendage on the left side, due to anatomic complexity. Short-term results are encouraging.

Complex aortopulmonary window in a single ventricle setting: Technical considerations for staged palliation.

We report a successful surgical management of a case presented with a combination of aortopulmonary window (APW) with large ventricular septal defect (VSD) amounting to a single ventricle, with a view to highlight technical considerations during staged single-ventricle palliation.

Transcatheter closure of a large ASD from the femoral vein in a patient with Budd-Chiari syndrome.

Anomalies of the inferior vena cava are rare in patients with isolated atrial septal defect (ASD). When present, they usually preclude successful transcatheter closure of the ASD using the femoral route. We report a case of a large secundum ASD in a 3-year-old child, who had a chronic Budd-Chiari syndrome incidentally detected on the cardiac catheterization table. We were able to successfully deploy the device from the femoral route itself using a collateral channel to reach the heart and then using the pulmonary vein deployment technique to successfully close the defect.

Iatrogenic diversion of IVC to left atrium after surgical closure of ASD.

Iatrogenic diversion of the inferior vena cava (IVC) to the left atrium during surgical closure of an atrial septal defect (ASD) is a very rare complication in the era of cardiopulmonary bypass. The eustachian valve could be mistaken for the margin of the ASD. We report a case with this complication after closure of a sinus venosus ASD of the IVC type.