title: Perventricular device closure of doubly committed subarterial ventral septal defect through left anterior minithoracotomy on beating hearts.
abstract: BACKGROUND
  Surgical repair of doubly committed subarterial ventricular septal defect (VSD) under cardiopulmonary bypass has been the gold standard with full median sternotomy, complicated by skin scarring and potential mortalities and morbidities from cardiopulmonary bypass. Perventricular device closure of muscular and then perimembranous VSD on beating heats with a small subxiphoid or inferior sternotomy has been attempted in the past few years with good results. We have tried perventricular closure of doubly committed subarterial VSD through a left anterior minithoracotomy as an alternative procedure with a modified occluder.
  
  
  METHODS
  Between January 2008 and December 2010, 6 selected patients with doubly committed subarterial VSD were recruited for modified device closure on beating hearts without cardiopulmonary bypass through left anterior minithoracotomy involving a short incision through the third intercostal space. Their ages ranged from 18 to 46 months and their body weights from 11 to 23 kg. A single per-right ventricular "U" like suture under pulmonic annulus was established, and a delivery system was introduced, aided by an 18G trocar, including a guidewire, delivery sheath, and loading sheath. A proper device was selected according to the VSD size established by transesophageal echocardiography (TEE), and then the device was released under real-time monitoring of TEE if no residual shunt, increased aortic prolapse or regurgitation, abnormal atrioventricular valvular motion appeared.
  
  
  RESULTS
  In 5 of the 6 children, the device was successfully closed through a left minithoracotomy with satisfactory cosmetic effects. In the other child, the procedure was converted to conventional open-heart repair because the relatively larger occluder induced significantly increased aortic regurgitation. There was no operative or late mortality or major morbidity. All children were followed up for 10 to 21 months. No residual shunt, increased aortic prolapse or regurgitation, or serious atrioventricular block was recorded until the most recent follow-up.
  
  
  CONCLUSIONS
  Selected doubly committed subarterial VSD can be safely closed with a proper occluder through left anterior minithoracotomy. The Cosmetic results are highly satisfactory.
authors.affiliation: Heart Center, Children's Hospital, Qingdao University, Qingdao, China.
authors.forename: Silin
authors.initials: S
authors.lastname: Pan
authors.forename: Quansheng
authors.initials: Q
authors.lastname: Xing
authors.forename: Qian
authors.initials: Q
authors.lastname: Cao
authors.forename: Pingshan
authors.initials: P
authors.lastname: Wang
authors.forename: Shuhua
authors.initials: S
authors.lastname: Duan
authors.forename: Qin
authors.initials: Q
authors.lastname: Wu
authors.forename: Kefeng
authors.initials: K
authors.lastname: Hou
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods*; D002675:Child, Preschool; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging / Q000601:surgery*; D006352:Heart Ventricles / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D011474:Prosthesis Design; D012189:Retrospective Studies; D055989:Septal Occluder Device; D013908:Thoracotomy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*