title: Closure of muscular ventricular septal defects guided by en face reconstruction and pictorial representation.
abstract: BACKGROUND
  A surface reconstruction of the location and dimensions of muscular ventricular septal defects (VSDs) on right ventricular (RV) septal surface could serve as a better guide to surgical closure amid different classifications and confusing terminologies.
  
  
  METHODS
  We reconstructed muscular VSD requiring surgery on an en-face view of the RV septal surface from echocardiographic orthogonal views in 34 consecutive patients. The location, dimensions of the defects, and relation to various RV septal landmarks are illustrated as a diagram. Recommendations are presented regarding surgical approach to the defects, along with predictions on the possibility of residual defects and heart block.
  
  
  RESULTS
  Surgical findings were as predicted by the diagram in the 27 patients who underwent VSD closure. Seven infants (2.5 to 4.9 kg) underwent pulmonary artery (PA) banding based on predictions of heart block or major residual defects. Two patients with predicted risk of heart block underwent VSD closure with heart block ensuing in one of them. Based on the diagram limited ventriculotomy (n = 2) or detachment of tricuspid leaflets (n = 6) aided access to the VSD. Among patients undergoing VSD closure only 1 patient had a major residual defect that required PA banding. There were clinically insignificant residual defects in 8 patients. Four patients (12%) were anticipated preoperatively because of surgical inaccessibility and intentionally left alone.
  
  
  CONCLUSIONS
  En-face reconstruction of single or multiple muscular VSDs is feasible from orthogonal echocardiographic views. It helps plan the surgical approach and predict the likelihood of heart block and residual defects after surgery.
authors.affiliation: Department of Pediatric Cardiology, Amrita Institute of Medical Sciences & Research Center, Kochi, India. rkrishnakumar@aimshospital.org
authors.forename: Kothandam
authors.initials: K
authors.lastname: Sivakumar
authors.forename: Sivadasan Radha
authors.initials: SR
authors.lastname: Anil
authors.forename: Suresh G
authors.initials: SG
authors.lastname: Rao
authors.forename: Krishnanaik
authors.initials: K
authors.lastname: Shivaprakash
authors.forename: Raman Krishna
authors.initials: RK
authors.lastname: Kumar
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D002675:Child, Preschool; D015331:Cohort Studies; D015150:Echocardiography, Doppler / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006334:Heart Function Tests; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging* / Q000601:surgery*; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D007223:Infant; D008297:Male; D011336:Probability; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D015996:Survival Rate; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000000981:diagnostic imaging / Q000601:surgery*