This document describes surgical techniques for repairing various types of ventricular septal defects (VSDs). The key approaches discussed are through the right atrium, right ventricle, or left ventricle/pulmonary trunk depending on the location and size of the defect. The repair is typically done using cardiopulmonary bypass and cold cardioplegia. Patches are often used to close the defect and care must be taken to avoid damaging nearby structures like the bundle of His. Post-operative care may involve monitoring for heart block or residual shunting. With experienced surgeons, mortality rates are now less than 1% for isolated VSD closure.

1. VSD Repair
Surgical techniques
-RAJA LAHIRI

2. • VSDs are repaired either through the right
atrium, RV, or in special circumstances, LV or
pulmonary trunk
• Currently, RV and LV approaches are rarely used
• Repair is done on conventional CPB at 20°C to
28°C with direct caval cannulation
• For infants weighing less than 3kg, a single
venous cannula may be used and the repair is
performed during hypothermic circulatory arrest
• Cold cardioplegia is used in all the cases

3. • After the usual anesthetic and surgical preparations, a
median sternotomy is made.
• Presence of anomalies of pulmonary or systemic
venous return is determined.
• An open ductus during open cardiotomy, particularly
during hypothermic circulatory arrest, allows air to
enter the aorta and later migrate to the brain; during
CPB an open ductus increases intracardiac return and
overdistends the pulmonary circulation.
• A patent ductus is ligated from the anterior approach,
usually during cooling.
• In neonates and infants undergoing hypothermic
circulatory arrest, the ductus is ligated as a routine
procedure.

4. Repair of Perimembranous Ventricular
Septal Defect
• After CPB has been established, the aorta is occluded, cold
cardioplegic solution injected, and the right atrium opened
obliquely.
• A suction device is placed across the naturally present or
surgically created foramen ovale
• Before repair is started, the defect is carefully examined to
establish that all margins can be seen and reached.
• In rare circumstances in which this is not possible because
of chordal arrangement, an incision is made to disconnect a
portion of the tricuspid valve from the annulus, and the
VSD is exposed through the resulting aperture.
• Relationship of the bundle of His to the posterior and
inferior margins of the defect must be clearly understood to
accomplish a safe repair.

5. • In older infants and children, the VSD is repaired
with a polyester or dacron patch sewn in place
with continuous polypropylene sutures.
• In neonates and small infants, the technique may
not be adequate because of the delicate nature
and friability of the structures.
• In these patients, the patch may be sewn into
place using a combination of continuous and
interrupted pledgeted mattress sutures or,
alternatively, employing exclusively interrupted
mattress sutures reinforced with small pledgets.

8. • A ventricular approach may be used when the VSD cannot
be well visualized from the right atrium.
• An RV approach is performed through a transverse incision.
• The patch is sewn into place with continuous or interrupted
sutures.
• Suturing begins at the transition point between the septal
leaflet of the tricuspid valve and the ventricular septum, 5
to 7 mm below the edge of the septal defect.
• This critical point is given attention by all experienced
surgeons.
• Usual de-airing procedures are performed, and the
remainder of the operation is completed as usual

11. Repair of Doubly Committed Subarterial Ventricular
Septal Defect
• Transverse incision in the RV infundibulum is the classic
approach for repair of doubly committed subarterial VSDs.
• These defects should always be closed with a patch to
reduce the possibility of distorting the semilunar valves.
• A continuous stitch technique is employed.
• When pledgeted sutures are used, they are placed from
just above the pulmonary valve leaflets, and pledgets come
to lie in the pulmonary valve sinuses.
• Care is taken not to damage the left main coronary artery.
• An approach through the pulmonary trunk is also
convenient for repairing doubly committed subarterial
VSDs.

13. Repair of Inlet Septal Ventricular
Septal Defect
• Inlet septal (AV septal type) VSD is most easily repaired
through the right atrium.
• Such defects are always repaired with a patch.
• The defect lies beneath the septal leaflet of the
tricuspid valve, and care is taken to avoid damage to
the leaflet or its chordae and to tailor the patch such
that it is not too bulky beneath the leaflet.
• One method of avoiding damage to the leaflet and
improving exposure is to temporarily detach the base
of the septal leaflet and a portion of the anterior
leaflet of the tricuspid valve and retract the leaflet
anteriorly.

14. Repair of Muscular Ventricular Septal Defect
• A right-sided approach is used for repair of muscular VSDs.
• Left ventriculotomy provides excellent exposure and
although it has been reported not to be disadvantageous in
infants, it can produce ventricular aneurysm and important
LV dysfunction early and late postoperatively.
• Defects in the lower part of the muscular septum may be
obscured by trabeculations and thus difficult to visualize,
resulting in incomplete closure.
• Single or multiple muscular defects in the inlet and
trabecular septum are approached through the right
atrium.
• When a single defect is slit like or oval, direct suture is
satisfactory, but when it is large and circular, a patch is
used.
• A cluster of defects can be closed with a single patch or
individually.

15. • Division of RV trabeculations can aid exposure of the
defects, which may be difficult to close because of
multiple sites of jet penetration.
• A single patch of autologous pericardium supported by
pledget-reinforced sutures covering an extensive
portion of the trabecular septum is useful when there
are multiple defects.
• Kitagawa and colleagues described resection of
trabeculations to expose the defect and attaching an
oversized patch to the left side of the ventricular
septum by sutures passed through the septum from
the left side.
• They also described placing pledget-supported sutures
through the rim of an anterior muscular defect, passing
the sutures to the outside and tying down on the
epicardial surface

16. • When a muscular VSD coexists with a
perimembranous VSD, a single patch may be used
to avoid damaging the bundle of His.
• VSDs with a single LV opening but two or more
openings into the RV on both sides of the
trabecula septomarginalis are also approached
through the right atrium.
• The defect is converted into a single LV orifice by
detaching the lower end of the trabecula
septomarginalis and moderator band from the
septum and retracting them

17. • Multiple defects in the anterior portion of the
septum may be closed through a high
transverse ventriculotomy.
• At times, VSDs may be considered too
numerous to close individually; these VSDs are
simply compressed and often totally closed by
interrupted mattress sutures between a felt
strip on theanterior ventricular wall (away
from the left anterior descending coronary
artery) and pledgets inside the RV and inferior
to the VSDs

18. • The rare Swiss cheese septum, with features
resembling ventricular noncompaction (spongy
ventricular septum) and defects involving all
components of the ventricular septum may not be
correctable through the right side.
• Its repair requires an LV approach, and a patch over the
entire muscular septum may be necessary
• Incisions into both ventricles are avoided whenever
possible.
• Great care is used in making and closing the left
ventriculotomy incision so as not to damage coronary
artery branches.

19. VSD with PDA
• Dissection of the ductus arteriosus is done after
establishing CPB
• The heart must continue to beat otherwise a large
shunt will rapidly overdistend the right side of the
heart and lungs as it steals from the systemic and
cerebral circulation.
• If the heart does fibrillate, CPB flow is immediately
reduced while the dissection is rapidly completed.
• One ligature, tied on the ductus while CPB flow is
reduced to lower intravascular pressure, is sufficient to
close it.
• A surgical clip may be used instead. The operation then
proceeds as usual.

20. RA versus RV Approach
for Perimembranous VSD
RA Approach
• Advantages
– An accurate repair can be
obtained through a right
atrial approach in nearly all
cases.
– Associated infundibular
pulmonary stenosis can be
excised.
– An RV scar is avoided
– Occurrence of RBBB is lower
than with the transventricular
approach
RV Approach
• Advantages
– the nadir of the noncoronary
cusp of the aortic valve,
which is the area of the right
trigone and bundle of His, can
be accurately visualized,
which may be helpful in
choosing the suture
technique that will minimize
prevalence of heart block

21. RA versus RV Approach
for Perimembranous VSD
RA Approach
• Disadvantages
– Techniques must be accurate
to avoid damaging the
tricuspid valve leaflets or
chordae.
RV Approach
• Disadvantages
– leaving a scar in the RV
– being associated with a
higher prevalence of
complete RBBB than with an
atrial approach
– More incidence of ventricular
arrhythmias late
postoperatively.

22. Closure of Ventricular Septal Defect
Through Less
Invasive Approaches
• Smaller incisions (less invasive approaches)
have been used for closure of VSDs.
• Although it is technically feasible to close a
VSD successfully through a variety of these
techniques, no advantages have been
demonstrated other than the smaller incision.

23. Percutaneous Closure of Ventricular
Septal Defects
• In selected cases, especially in patients with complex
cardiac anomalies (e.g., multiple muscular VSDs) and
those with overlooked VSDs after surgical repair of a
large defect, transcatheter closure of the VSD by a
percutaneously placed double umbrella can be
considered.
• This may be particularly advantageous in apical
muscular defects.
• This method in general should be considered only
when surgery is contraindicated or has unusually high
risks and when suitable skill and equipment are
available.

24. Closure of VSD When Pulmonary
Resistance Is High
• Patients with VSD in which pulmonary hypertension is
severe, with Ppa at or above systemic blood pressure,
have traditionally been thought to be inoperable
because of the high risk of operation
• Zhou et al advocated the use of unidirectional valve
patch closure of cardiac septal defects with severe
pulmonary hypertension
• The patch consists of polyester fabric with a 0.5- to 1.0-
cm hole covered by a pericardial patch left open at one
side to function as a one-way valve, placed on the
systemic side of the defect.

25. VSD & Aortic Regurgitation
• In patients in whom AR is trivial or absent,
only the VSD is repaired.
• When AR is moderate or severe and often
when it is mild, the aortic valve is repaired.
• The aortic valve is usually replaced in adults,
and this is done only when AR is moderate or
severe.

26. Trusler method of plication
• This procedure is carried out at the commissure adjacent to
the prolapsed cusp (usually the right or noncoronary cusp).
• A 5-0 or 6-0 polypropylene suture is placed through the
fibrous lacunae at the midpoint of each cusp.
• Cusps can then be assessed for elongation and attenuation.
• Cusp plication is performed at the elongated free edges of
the aortic valve cusps.
• A 5-0 or 6-0 PTFE suture is woven between the right and
noncoronary cusps to adjust the excessive length of the
prolapsed cusp to the adjacent aortic wall.
• Repair may be reinforced by pledgets (pericardial or felt) or
a small cap of polyester secured as a pledget over both
affected cusps adjacent to the commissure.

28. • An entirely different technique has been
successfully used by Carpentier, Chauvaud, and
colleagues.
• Its basic feature is triangular excision and
reconstruction of the prolapsing cusp.
• Combined with this is an anuloplasty of the left
ventriculoaortic junction.
• They also recommend that the VSD be repaired
through the aortic root, using a glutaraldehyde
treated pericardial patch.

29. • If the valve requires replacement, it is advisable
to do the repair of VSD first, followed by AVR
• This sequence is advised because occasionally it
may be necessary to place sutures from the
prosthetic valve ring across the upper margin of
the VSD patch where it extends between the base
of the right and noncoronary cusps (in the region
normally occupied by the membranous septum)

30. VSD and Coarctation of Aorta
• Management options for this combination of
defects include
– simultaneous repair of both lesions
– sequential single-stage repair through separate
incisions
– initial repair of the coarctation alone
– initial coarctation repair and pulmonary trunk
banding
– initial VSD closure alone

31. • With a large VSD and severe coarctation,
repairing the VSD first has certain theoretic
advantages but has been practiced rarely under
such circumstances
• Repair of the coarctation only as the initial
operation has the advantage of reducing
afterload on the LV and, theoretically at least,
reducing shunt through the defect.
• It also avoids a second operation if the VSD closes
spontaneously

32. • In the current era, the following practice can be
recommended:
1. When the VSD is large, the coarctation is severe, and the
infant presents with severe heart failure, a singlestage
repair of coarctation and VSD is advisable. When
multiple VSDs or Swiss cheese septum is present, the
pulmonary trunk is banded, and debanding and repair
are delayed if possible until the patient is about age 3
years.
2. When the coarctation is severe and VSD small or
moderate-sized, only the coarctation is repaired, and
subsequent repair of the VSD is performed according to
standard indications.
3. When the coarctation is moderately severe and VSD
large, the VSD may be repaired initially and the
coarctation repaired either at the same operation or as a
second procedure within a few months. Techniques of
CPB are standard, with perfusion of the lower body
satisfactory in this situation.

33. Pulmonary Trunk Banding
• There have been only two standard
indications for pulmonary trunk banding in
infants with primary VSD:
(1) severe heart failure from Swiss cheese
septum
(2) associated severe coarctation of the aorta
and severe heart failure during the first few
months of life.
The second is no longer an indication for banding

34. • Banding of the pulmonary trunk may be performed
through a small left anterolateral thoracotomy
• Nowadays banding is often to be followed by a Fontan
operation or use of a valved conduit, avoiding
distortion of the pulmonary trunk bifurcation by the
band is crucial.
• To ensure this, placement of the pulmonary trunk band
via median sternotomy is the best approach because it
permits accurate dissection, placement, and anchoring
of the band on both the left and right sides of the
pulmonary trunk.

35. • According to Trusler’s rule, in the case of patients with
a two-ventricle circulation, the pulmonary trunk band
is marked to a length of 20 mm, plus the number of
millimeters corresponding to the child’s weight in
kilograms, to indicate the ultimate tightness of the
band.
• If the banding is done for a complex cardiac anomaly
with mixed circulation, the length is 24 mm plus the
child’s weight.
• A 3- to 4-mm-wide tape is used. The preferred material
for the band is silicone or silicone-impregnated
polyester, which minimizes erosion into the pulmonary
trunk and allows easy removal.

36. SPECIAL FEATURES OF POSTOPERATIVE
CARE
• Hemodynamic state typically is good early postoperatively
after closure of VSD.
• In the unusual situation of poor hemodynamic
performance, the possibility of residual left-to-right
shunting must be considered particularly if left atrial
pressure is considerably higher than right atrial pressure
• If a large left-to-right shunt is present, prompt reoperation
is probably indicated.
• It is prudent to place temporary pacing wires on the RV
after VSD repair.
• Complete AV dissociation is often present for a short time
intraoperatively.
• Even if this resolves promptly, AV dissociation may occur
temporarily later on

37. RESULTS
• In the current era in experienced centers,
hospital mortality for isolated VSD closure is
1% or less.
• Risk is higher when VSDs are multiple and
when major associated cardiac anomalies
coexist

38. Mode of Early death
• The most common mode of death after repair of
a primary VSD is acute cardiac failure
• This may be related to failure of intraoperative
myocardial protection in the face of myocardial
dysfunction
• Pulmonary Hypertensive Crisis may precipitate
acute cardiac failure.
• Persisting severe pulmonary dysfunction, often
from viral pneumonitis present before operation,
characterizes death of a few infants after repair of
VSD