Evaluation of Three Different Techniques for the Closure of Ventricular Septal Defects

Ventricular septal defects (VSDs) are the most common type of congenital heart disease. Transcatheter device closure of a VSD is an established method of treatment with excellent reported results. With the advent of minimally invasive techniques, surgery has substantially evolved to include techniques such as the right lateral thoracotomy via the submammary crease for VSD closure, which has become a safe and cosmetic alternative to standard sternotomy. Lately, the transthoracic device closure has emerged as hybrid technique incorporating basic principles from both the transcatheter device closure as well as the traditional surgery. There is a paucity of randomized control trials comparing the effectiveness of these three methods. With this brief review we attempt to underline the basic principles of these techniques and evaluate their benefits and limitations. VSDs can be classified as muscular, supracrystal or perimembranous with the latter being the most common (around 80%) [1]. Surgical repair, which was introduced by Lillehei back in 1954, is still considered the mainstay of treatment [2]. However, this approach like every other surgical procedure carries inherent risks and has been associated with morbidity and mortality, patient discomfort and displeasing sternotomy scars [3]. Therefore, transcatheter approaches have become very popular over the last years. Since the first transcatheter VSD closure in the 80s [4], percutaneous techniques have been refined in an effort to minimize the unfavorable impacts of surgery. In response to the incremental use of transcatheter techniques, surgery has also evolved through minimally invasive incisions, mainly right lateral thoracotomy (RLT) and ministernotomy. Moreover, newer hybrid techniques, such as the transthoracic device closure, incorporate transcatheter interventional techniques with the aid of surgical principles. In the last issue of the journal we come across a retrospective comparative study of three techniques for VSD closure, namely the right lateral thoracotomy, the transthoracic and the transcatheter device closure [5]. In the absence of randomized control trials comparing the effectiveness of these three techniques, this study is worth of attention. The authors conclude that all methods are safe and feasible with good outcomes in short-term follow up. Furthermore, as expected, they report statistically significant differences in terms of mechanical ventilation and operative time, hospitalization and ICU stay, and blood transfusion rate in favor of the device groups. Nevertheless, both the device groups were associated with occasional complications such as serious arrhythmias and new onset aortic insufficiency, which necessitated conversion to the surgical method. The incidence of the reported complications was very low, while the results pertained to a small sample of patients (192). It is evident therefore, that all three methods are associated with high success rates and few reported complications. The authors are to be commended for the execution of their study and the reported results. We share with the authors the general understanding that currently surgery is still an irreplaceable choice with a wide range of indications. We must stress however, that the closure strategy has to be tailored to every individual VSD case. Herein, we briefly delineate the pros and cons of these three methods for the repair of the VSD.