Sandwich Technique for Mid-Muscular and Apical Ventricular Septal Defects Closure

Background: Surgical closure of mid-muscular and apical ventricular septal defects (VSDs) remains technically challenging. Conventional muscular repair techniques for the closure of these defects have been described over the years; early approaches often relied on combined right atriotomy and right or left ventriculotomies, with direct closure using Dacron patches, whereas more recently, a transatrial and transtricuspid approach has been adopted to create a ‘sandwich’ patch repair. In this study, we report our experience with a modified sandwich technique for the closure of mid-muscular and apical VSDs, designed to provide a reproducible blind repair strategy without the need for direct exposure of the defect. Objective: To describe the Naples experience with the modified Sandwich technique for surgical closure of mid-muscular and apical VSDs. Methods: The Sandwich technique employs a dual-patch strategy, with one patch advanced into the left ventricle through a transaortic approach and a second patch positioned via the tricuspid valve. This retrospective study included 17 pediatric patients who underwent muscular VSD closure using the Sandwich technique between June 2015 and December 2024. Demographic, operative, and follow-up data were collected and analyzed. Results: 2 Median age and weight at surgery were 5.2 months (range: 0.2–41.4 months) and 6.15 kg (range: 2.9–14.5 kg), respectively. Eleven patients (65%) had undergone previous interventions, including 3 catheter-based procedures (18%) and 8 prior surgical operations (47%). Median cardiopulmonary bypass time was 158 minutes (range: 95–275 minutes), with a median aortic cross-clamp time of 107 minutes (range: 67–204 minutes). Dual-patch closure was achieved via a transaortic approach in 11 patients and via a transatrial approach in 6 patients; small right ventriculotomy was required in 3 cases. The median follow-up was 25.7 months (range, 0.1–103.5 months). No patient exhibited a residual shunt greater than minimal-to-mild, or hemodynamically significant, at follow-up. No postoperative of mitral or aortic valve dysfunction was observed. Overall survival was 88%, with two deaths (11.8%) during the study period. Conclusions: The Sandwich technique is a safe and reproducible option for the surgical closure of complex mid-muscular and apical VSDs across a wide age and weight range, including neonates. In selected patients, this approach enables effective defect closure while avoiding ventriculotomy, thereby preserving ventricular and valvular function and potentially reducing the need for additional surgical, interventional, or hybrid procedures.

Background: Surgical closure of mid-muscular and apical ventricular septal defects (VSDs) remains technically challenging. Conventional muscular repair techniques for the closure of these defects have been described over the years; early approaches often relied on combined right atriotomy and right or left ventriculotomies, with direct closure using Dacron patches, whereas more recently, a transatrial and transtricuspid approach has been adopted to create a ‘sandwich’ patch repair. In this study, we report our experience with a modified sandwich technique for the closure of mid-muscular and apical VSDs, designed to provide a reproducible blind repair strategy without the need for direct exposure of the defect. Objective: To describe the Naples experience with the modified Sandwich technique for surgical closure of mid-muscular and apical VSDs. Methods: The Sandwich technique employs a dual-patch strategy, with one patch advanced into the left ventricle through a transaortic approach and a second patch positioned via the tricuspid valve. This retrospective study included 17 pediatric patients who underwent muscular VSD closure using the Sandwich technique between June 2015 and December 2024. Demographic, operative, and follow-up data were collected and analyzed. Results: Median age and weight at surgery were 5.2 months (range: 0.2–41.4 months) and 6.15 kg (range: 2.9–14.5 kg), respectively. Eleven patients (65%) had undergone previous interventions, including 3 catheter-based procedures (18%) and 8 prior surgical operations (47%). Median cardiopulmonary bypass time was 158 minutes (range: 95–275 minutes), with a median aortic cross-clamp time of 107 minutes (range: 67–204 minutes). Dual-patch closure was achieved via a transaortic approach in 11 patients and via a transatrial approach in 6 patients; small right ventriculotomy was required in 3 cases. The median follow-up was 25.7 months (range, 0.1–103.5 months). No patient exhibited a residual shunt greater than minimal-to-mild, or hemodynamically significant, at follow-up. No postoperative of mitral or aortic valve dysfunction was observed. Overall survival was 88%, with two deaths (11.8%) during the study period. Conclusions: The Sandwich technique is a safe and reproducible option for the surgical closure of complex mid-muscular and apical VSDs across a wide age and weight range, including neonates. In selected patients, this approach enables effective defect closure while avoiding ventriculotomy, thereby preserving ventricular and valvular function and potentially reducing the need for additional surgical, interventional, or hybrid procedures.