Hybrid Approach: Defect Closure

Abstract

Transcatheter closure of septal defects in small children is technically challenging. In particular, there is difficulty in passing the long delivery sheath without compromising valvar and ventricular function. While surgical closure is often appropriate in these patients, when the defect is inaccessible without a ventriculotomy, then a hybrid approach produces the greatest benefit to the patient. Through the open chest, a purse-string suture is placed in the right ventricle opposite the site of the VSD. Using transoesophageal or epicardial echocardiography, a guidewire is placed across the defect after needle puncture of the right ventricular free wall. A short sheath is then advanced across the defect and using echocardiographic monitoring a septal occluder deployed to close the defect. Once a satisfactory position is obtained, the device is detached from the delivery cable and the purse-string suture tightened after sheath withdrawal. While usually performed electively off bypass, the procedure can also be performed while on cardiopulmonary bypass as an adjunct to concomitant surgery or when a defect is unexpectedly unable to be closed surgically.