Surgical management of trabecular ventricular septal defects: the sandwich technique

Surgical closure of trabecular ventricular septal defects is difficult and often unsuccessful.

We performed closure of trabecular ventricular septal defects by sandwiching the septum between 2 polyester felt patches placed in the left ventricle and right ventricle without ventriculotomy.

Eleven patients (7 boys and 4 girls) underwent a sandwiching closure at a mean age of 4.7 years (range, 0.4-9.7 years) and a mean weight of 16.7 kg (range, 4.6-52 kg). Associated cardiac malformations were present in 9 of the 11 patients. Seven patients had undergone previous operations. The trabecular ventricular septal defects are exposed through the tricuspid valve and also from the left ventricular side through a coexisting large perimembranous ventricular septal defect or through the mitral valve through an interatrial septostomy. Two forceps, one each from the right and left ventricular side, lead a 3F Nelaton catheter through the trabecular defect. An oversized circular polyester felt patch mounted on a 3-0 Nespolen suture attached to the Nelaton catheter is then passed into the left ventricle. The suture ends are then passed through a slightly smaller polyester felt patch on the right ventricular side of the septum. The Nespolen suture is then tied, thereby sandwiching the septum between the 2 patches.

Time required for the procedure was less than 20 minutes in each case. There were no hospital deaths, and the postoperative course was uneventful in all patients. There was no residual shunt in 3 patients, and a minimal residual shunt was observed in 5 patients. Mild residual shunt was observed in 3 patients. Cardiac catheterization was performed 1 month postoperatively in 8 patients in whom residual shunt was noted on echocardiography. Five of 8 patients had a minimal residual shunt (pulmonary blood flow/systemic blood flow ratio = 1.0). Three patients had a residual shunt (pulmonary blood flow/systemic blood flow ratio = 2.0, 1.6, and 1.2). The patient with a pulmonary blood flow/systemic blood flow ratio of 2.0 had a "Swiss cheese" ventricular septal defect, and a residual shunt remained around the patch. However, the residual shunt decreased to a pulmonary blood flow/systemic blood flow ratio of 1.6 at examination 16 months postoperatively. Echocardiography showed that the residual shunt had also decreased in another 2 patients.

We conclude that the sandwich technique is safe and easy. Even in cases with a residual shunt present, the shunt is expected to decrease as time passes. Further experience and longer follow-up of these patients are necessary to conclude whether this technique is applicable to neonates and young infants.