Perimembranous VSD Patch Closure (Video)

Date
March 28, 2026
URL
https://x.com/WithAScalpel/status/2037864638633726033?s=20
Categories
VSDCardiac SurgerySurgical Training

Perimembranous VSD Patch Closure (Video) đŸŽ„

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Anatomy and Surgical Imperatives

Perimembranous ventricular septal defects (pmVSDs) sit at the confluence of the membranous septum, septal leaflet of the tricuspid valve (TV), and the right/non-coronary cusps of the aortic valve (AV). This anatomic crossroads imposes two non-negotiables: (1) protect the atrioventricular (AV) conduction axis along the posteroinferior rim; and (2) preserve leaflet geometry and coaptation at the aortic/anterosuperior margin and at the TV interface [1,2].

Exposure and Orientation

A right atriotomy is the standard approach. After retracting the septal leaflet, delineate the pmVSD edges. The anterosuperior (aortic) rim is adjacent to the right (and variably the non-coronary) aortic cusps; the suture corridor often aligns with the junction of the trabecula septomarginalis and the infundibular septum. The posteroinferior rim overlies the penetrating His bundle and proximal right bundle branch; the base of the medial papillary muscle remains a reliable waypoint for safe needle trajectories [1,2,3].

Suture Strategy: Interrupted vs Running

Both interrupted and continuous techniques are acceptable. Many surgeons favor interrupted pledgeted sutures for teaching clarity and traction control, whereas others prefer a fine continuous line for uniform apposition and fewer knots—particularly when exposure is optimized (e.g., with selective TV detachment) [1,3,4]. Choice should be individualized to exposure and tissue quality.

Stepwise Technique

1) Parachute the patch. Place initial anchoring stitches on the anterosuperior rim and parachute the tailored patch into position. This rim is relatively free of conduction tissue; maintain respect for the AV annulus and aortic leaflets [1,2].

2) Run or place interrupted sutures along the anterosuperior margin. Keep bites orthogonal to the septal plane, with cautious depth near the aortic annulus. If leaflet relations are uncertain, pause and directly inspect the aortic cusps during cardioplegic arrest [1].

3) Navigate the posteroinferior rim. As the line turns inferiorly, bias a millimeter or two onto healthy septum and favor shallow, tangential bites to protect the AV node/His bundle [1,2,5].

4) Traverse the TV interface, as needed. When the defect abuts the septal leaflet, an “in-and-out” running segment or short interrupted bites through the leaflet edge can maintain alignment. If visualization is limited, temporary tricuspid valve detachment (TVD)—usually a short incision near the annulus—improves exposure without harming long-term valve function when meticulously repaired [4,6].

5) Tie on the right atrial side. Finish on the atrial surface to minimize foreign material in the ventricle and streamline de-airing [1].

Key Hazards and How to Mitigate

  • Conduction injury (CAVB). Risk peaks along the posteroinferior rim. Countermeasures: slightly oversize the patch, keep the suture line offset from the true rim, use shallow/tangential bites, and avoid bite-through of the muscular crest near the medial papillary base [1,2]. Contemporary surgical series report permanent pacemaker implantation for AV block in ~0.8–1.1% overall (and ~<1% in isolated VSDs) when modern technique is applied [7,8].
  • Aortic leaflet entrapment/prolapse. Maintain direct visualization at the anterosuperior margin; avoid deep stitches that capture cusp tissue; reassess leaflet motion before weaning from bypass [1].
  • Tricuspid regurgitation. Keep the leaflet traversal level and tension even. When exposure is difficult, selective TVD is safe and does not worsen long-term TR compared with no detachment [4,6].
  • Residual shunt. Ensure uniform bite spacing and patch lay; a gentle continuous line or well-spaced interrupted sutures both succeed if apposition is even. Test with saline and confirm with intraoperative echocardiography [1,3].
Context vs devices. For pmVSDs, transcatheter occlusion carries a higher and later risk of complete AV block than surgical patch closure in many series; device-related CAVB can occur months to years post-implant [9]. This comparison reinforces meticulous conduction-sparing technique during surgical repair.

Final Checks

Perform de-airing and a volume challenge. Transesophageal echocardiography (TEE) should confirm: (1) no significant residual VSD; (2) preserved AV and TV function; (3) intact septal motion with stable rhythm and no new conduction disturbance. When uncertain near the conduction axis, favor tissue respect over tightness—a slightly larger patch with gentle, evenly spaced bites is safer than an over-tight line in a hazardous zone [1,2].

References

[1] Manning PB. Ventricular Septal Defect Closure: How I Teach It. Ann Thorac Surg. 2018;106(2):324-326. PubMed

[2] Mavroudis C, Backer CL. Closure of ventricular septal defect. Oper Tech Thorac Cardiovasc Surg. 2002;7(1):11-21. Northwestern Scholars

[3] Mullen JC, Lemermeyer G, Schipper SA, Bentley MJ. Perimembranous ventricular septal defect repair: keeping it simple. Can J Cardiol. 1996;12(9):817-821. PubMed

[4] Maile S, Kadner A, Turina MI, PrĂȘtre R. Detachment of the anterior leaflet of the tricuspid valve to expose perimembranous ventricular septal defects. J Thorac Cardiovasc Surg. 2003;125(2):944-946. PubMed

[5] de Leval MR, McKay R, Jones M, Stark J, Macartney FJ. Surgical technique to reduce the risks of heart block after closure of ventricular septal defect. Br Heart J. 1979;41(3):289-292. PubMed

[6] Fraser CD 3rd, Zhou X, Palepu S, et al. Tricuspid Valve Detachment in Ventricular Septal Defect Closure Does Not Impact Valve Function. Ann Thorac Surg. 2018;106(1):145-150. PubMed

[7] Tucker EM, Pyles LA, Bass JL, Moller JH. Permanent pacemaker for atrioventricular conduction block after operative repair of perimembranous ventricular septal defect. J Am Coll Cardiol. 2007;50(12):1196-1200. PubMed

[8] Andersen HØ, de Leval MR, Tsang VT, et al. Is complete heart block after surgical closure of ventricular septum defects still an issue? Ann Thorac Surg. 2006;82(3):948-956. PubMed

[9] Predescu D, Chaturvedi RR, Friedberg MK, Benson LN, Ozawa A, Lee KJ. Complete heart block associated with device closure of perimembranous ventricular septal defects. J Thorac Cardiovasc Surg. 2008;136(5):1223-1228. PubMed

(Heart model used with permission from CrossMedical, Inc.)