FIG 31.48 Technique in which neither of the bridging leaflets is cut nor sutured directly to the ventricular septal crest An interventricular patch is inserted and attached to the right side of the septal crest, which is exposed by gently retracting the bridging leaflets one at a time with a retractor The bridging leaflets are sandwiched between the interatrial and interventricular patches All techniques have their own indications and supporters, and publications on all techniques exist No systematic trial has been carried out to draw conclusions on their merits Publication bias has it that usually only desirable results are published (Table 31.1) The major advantage of the technique using only one patch is the excellent exposure of the entire ventricular septal crest, so that suturing of the ventricular patch is made much easier The major disadvantage is the valvar suture line Friable valvar tissue might tear In addition, the suture line takes up some valvar tissue, thus enhancing central regurgitation The suture lines also introduce the danger of disruption, particularly in the setting of postoperative endocarditis The attraction of suturing the bridging leaflets directly to the ventricular septal crest is the obvious simplicity of the procedure because placement of the more difficult of the two patches is eliminated entirely.66 Intuitively, one might presume that this strategy could result in narrowing of the left ventricular outflow tract, but in practice this does not happen.67 Additional concerns about distortion of the valvar apparatus, particularly if the “scooped out” septal defect is deep, have not been refuted because techniques are used selectively When the distance between septal crest and valvar leaflets is more than 12 mm, Backer considers this an indication for a two-patch technique for fear of valvar distortion Midterm results have been reported by Karl and colleagues, but long-term results are largely lacking.68 A personal communication from the late Benson Wilcox, who was the first to advocate this policy, made it clear that he employed this technique only if the ventricular defect was not too deep Table 31.1 Results of Surgical Correction in Selected Series Reference Maximum Period of Follow-Up Inclusion (Years) All operated 1958– 43 partial defects 2000 All operated 1973– 28 defects 1997 All operated 1983– 21 partial defects 2002 All operated 1955– 40 partial defects 1995 Defect Type Welke105 (2007) Frid96 (2004) Murashita106 (2004) ElNadjawi107 (2000) Guenther97 All operated complete (1998) defects 1974– 1995 20 No of Operated Patients 133 Survival at 5 Years 90 Survival at 10 Years 88 Survival Survival at 20 at 40 Years Years 86 78 502 79 77 61 — 61 94 91 91 — 334 94 93 87 76 320 80 78 78 — The tissues of the valvar leaflets are rarely normal and are often deficient It is illogical in our opinion, therefore, to further reduce the amount of tissue available for repair Above all, unless bridging of one or both leaflets is minimal, we feel it to be unnecessary when these leaflets can easily be sutured to the patch without having to be cut The choice between a single patch and two patches, therefore, should in our opinion depend on the anatomy of the individual bridging leaflets Only when both inferior and superior leaflets bridge the septum extensively is a two-patch technique warranted In all other anatomic variants a single patch can be used This single patch must be incised to accommodate any leaflet that bridges extensively (see Fig 31.43) Thus, instead of employing one or two patches dogmatically, our approach is not to cut leaflets unless it proves impossible to visualize the location of intended stitches, which is an unusual circumstance Patches can be fashioned from synthetic material or from autologous or xenologous pericardium Synthetic fabric is sturdy, but its surface should be smooth to prevent hemolysis by a regurgitant jet Pericardium is always smooth and pliable, so it is our preferred choice Autologous pericardium should probably be treated for 5 minutes in 0.2% glutaraldehyde in order to prevent distension and aneurysmal widening, specifically of the interventricular patch.69 Some surgeons tell us that they use only fresh pericardium and obtain excellent results Our favorite operative technique is illustrated in Figs 31.49 to 31.56 FIG 31.49 Intraoperative images (through Fig 31.56) from a patient with Down syndrome aged 6 months, weighing 7.1 kg and having a body surface area of 0.38 m2, elevated pulmonary vascular resistance, and additional obstruction in the left ventricular outflow tract produced by accessory valvar tissue The series shows the view of the atrioventricular junction obtained by the surgeon working through the opened right atrium A retractor elevates the right ventricular lateral aspect of the common atrioventricular valve In this heart, empty as a result of cardioplegia, the valvar leaflets are flaccidly lying in the junction The left ventricle is on the small side, and the diameter of the left part of the atrioventricular valve is 14 mm, which is typical for the size of the patient The mural leaflet, in keeping with the smallish left ventricle, is also very small, with an angular annular size of approximately 45 degrees The superior bridging leaflet crosses the ventricular septum only minimally, typical of the so-called Rastelli A configuration The ventricular septal crest is bare