SURGICAL CLOSURE OF MUSCULAR VENTRICULAR SEPTAL-DEFECTS USING DOUBLE UMBRELLA DEVICES (INTRAOPERATIVE VSD DEVICE CLOSURE)

Objectives: Surgical closure of some muscular ventricular septal defec ts has been proven to be difficult, In order to simplify the surgical technique we have used intraoperatively Rashkind double umbrella devic es to occlude muscular ventricular septal defects, Methods: On the bas is of haemodynamic and echocardiographyc study five children aged 4, 6 , 7, 14 and 41 months were considered suitable candidates for intraope rative closure of muscular ventricular septal defects (midmuscular in three cases, apical in two) by Rashkind devices. Three of them had pre viously undergone pulmonary artery banding at 10, 11 and 41 days, resp ectively. During hypothermic cardiopulmonary by pass a delivery system was introduced across the tricuspid valve into the right ventricle an d then passed through the ventricular septal defect; the distal umbrel la of a 17 mm device was opened in the left ventricular cavity, a trac tion was applied to the introducer and the proximal umbrella was opene d on the right side straddling the interventricular septum, the device was then secund on the right side by few stitches. In one case becaus e of the wide diameter of the ventricular septal defect two umbrellas were used. The surgical procedure was completed with debanding and/or closure of other defects close to the aortic or tricuspid valve. Resul ts: Immediate results, tested by epicardial or transesofageal echo? sh owed a minimal residual shunt in 4 patients and a moderate shunt in on e. No early deaths occurred, 4 complete atrioventricular block develop ed in 1 patient who had an additional perimembranous defect closed wit h a prosthetic patch: a permanent pace maker was inserted 3 months aft er the operation. There was a late death for untractable right ventric ular failure in 1 patient who had a large residual shunt erroneously c onsidered moderate. In this patient, the size of the defect was undere stimated both preoperatively then. intraoperatively. The four survivor s are doing well with no signs of hemodynamically significant residual shunts. Conclusions: The use of Rashkind umbrella devices for closing intraoperatively muscular defects can be helpful to standard surgical techniques when technical problems make patch closure difficult. Its use avoid the need of left ventriculotomy. Careful definition of the s ize of the defect is mandatory to select suitable candidates. (C) 1997 Elsevier Science B.V.