Transatrial Approach to the “Swiss-cheese” Ventricular Septal Defects: Re-endocardialization Technique

Transatrial re-endocardialization (TAR) is a technique used to complement conventional patch repair of multiple ventricular septal defects (mVSD). To inform operative strategy, pre-operative imaging is supplemented by pre-cardiopulmonary bypass (CPB) intraoperative epicardial echocardiography to understand the size and location of all VSDs. After standard cannulation and arrest, L-shaped right atriotomy is performed and the superior margin of VSDs are marked. Perimembraneous and moderate-large VSDs with insufficient surrounding trabeculae are closed with patch repair. Remaining small muscular VSDs are addressed by TAR, whereby the defect is closed in 2-layers with fine polypropylene suture for superficial re-approximation of adjacent right ventricular trabeculation. Success of repair is evaluated with high-pressure left ventricular injection and pulmonary-systemic flow ratio after CPB is weaned. Adding TAR to the armamentarium of mVSD repair strategies allows for reduction of patch size, thereby decreasing the risk of ventricular septal dyskinesis and heart block.