Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results. 
Both surgical management and percutaneous device closure of muscular ventricular septal defects have drawbacks and limitations.  This report describes our initial experience with intraoperative device closure of muscular ventricular septal defects without cardiopulmonary bypass in 6 consecutive patients.  A median sternotomy or a subxiphoid minimally invasive incision was performed.  Under continuous transesophageal echocardiographic guidance, the right ventricle free wall was punctured, and a wire was introduced across the largest defect.  The Amplatzer (AGA Medical Corporation, Golden Valley, Minn) muscular ventricular septal defect occluding device (a self-expandable double-disk device) was used.  An introducer sheath was fed over the wire, with the sheath tip positioned in the left ventricle cavity.  The device was then advanced inside the sheath and deployed by retracting the sheath.  Associated cardiac lesions, if any, can then be repaired during cardiopulmonary bypass.  A similar technique can also be applied for periatrial closure of complex atrial septal defects.  The initial 6 patients are presented.  Cardiopulmonary bypass was not needed in any patient for placement of the device and needed in 4 patients for repair of concomitant malformations only (double-outlet right ventricle, aortic arch hypoplasia, pulmonary artery band removal).  No complications from using this technique occurred.  Discharge echocardiograms showed no significant shunting across the ventricular septum.  Perventricular closure of multiple muscular ventricular septal defects is safe and effective.  We believe that this could become the treatment of choice for any infant with muscular ventricular septal defects or any child with muscular ventricular septal defect and associated cardiac defects.