Thorax (1965), 20, 278.

Surgical treatment of ventricular septal defectVIKING OLOV BJORK

From the Department of Thoracic Surgery, University Hospital, Uppsala, Sweden

Since the first report of direct vision closure ofventricular septal defects in eight patients byLillehei, Cohen, Warden, Ziegler, and Varco(1955), and further pioneering work by Lilleheiand his group and by Kirklin, Harshbarger,Donald, and Edwards (1957), the surgical treat-ment of ventricular septal defect has been a wellestablished and accepted procedure. In 1957Lillehei and his associates reported a study of154 patients who had ventricular septal defectsand who were operated on with 45 deaths, givingan overall mortality of 293 00. Cleland and hisassociates in 1958 reported 15 patients operatedon with ventricular septal defects with only onedeath. Cooley (1959) reported a series of 130patients operated on for ventricular septal defects.Of those under 1 year of age at operation therewas a mortality of 41% in a group of 29 patients.In 10 patients between the ages of 1 and 2 yearsthere was a mortality of 30%. In the group be-tween 2 and 5 years the mortality dropped downto 6%. The conclusion Cooley drew from this wasthat if possible the operation should be postponeduntil the child is 18 months old.The aim of this paper is to give an account of

continued experience with the transatrial approachfor closure of a ventricular septal defect (Bjork,1964), a method first recommended by Kay andothers (1960).

INDICATIONS

Regarding the indications for closure of ventri-cular septal defects, I consider that patients witha significant shunt and normal pressures shouldhave their ventricular septal defects closed at arelatively early stage. Such a defect may not bemuch more than 10 mm. in diameter and may notgive serious symptoms until late in life. For ex-ample, a woman who was 50 years old when firstseen had had a murmur since the age of 9 years.The heart size was 650 ml./m.2 body surface, andheart catheterization showed a shunt of 50% onthe ventricular level with a systolic pulmonaryartery pressure of 35 mm. Hg. On account of herage and normal pressures in the pulmonary artery

the patient was not operated on but was observed.After one year there was a slight increase in theheart size to 700 ml./m.2 body surface, and twoyears after the first investigation the heart had in-creased in size to 800 ml./m.2 body surface;operation was then advised. During this procedurethe right ventricular pressure was found to haveincreased to 75/10 mm. Hg, and a ventricularseptal defect of 10 to 15 mm. in diameter wasclosed with a patch. Immediately after the opera-tion there was only a slight decrease in the rightventricular pressure from 75 to 60 mm. Hg andthe patient needed post-operative respirator treat-ment for 10 days.Three years after surgery the patient is in good

condition, and the right ventricular pressure hasdecreased to 28 mm. Hg; the size of the heart hasalso decreased to 690 ml./m.2. However, the work-ing capacity was only 300 kilopondmeters/min.,suggesting irreversible damage by the extra work-load on the heart for so many years. At a work-load of 250 kilopondmeters/min. the rightventricular pressure had risen from 28/3 mm. Hgto 55/5 mm. Hg. I think this case illustrates whatcan happen when a patient has a medium-sizedventricular septal defect, a normal pulmonaryarterial pressure, a significant shunt but no othersymptoms. After many years there may be asudden deterioration with increased pulmonaryarterial pressure leading to a dilatation of theheart and severe symptoms. Therefore I believepatients without symptoms but with a significantshunt of 50% should be accepted for surgery at anearly stage, and even in childhood. The decision toaccept patients with symptoms, with an enlargedheart, and with significant shunts is easier to make,also patients with a very high pulmonary arterialpressure should be operated upon as long as thereis a dominating left to right shunt on the ventri-cular level. Only the presence of severe pul-monary vascular resistance leading to reversal ofthe intracardiac shunt constitutes a contraindica-tion to surgery.

In this study the right ventricular pressure wasabove 70 mm. Hg in 14 patients, between 40 and69 mm. Hg in 10 patients, and below 40 mm. Hgin five patients.

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Surgical treatment of ventricular septal defect

TECHNIQUE

In the first instance the direct suture techniquedescribed by Kirklin et al. (1957) was used with tworecurrences of the shunt in 14 cases of ventricularseptal defect and with two recurrences in 11 cases ofFallot's tetralogy. Then a second layer of stitcheswas inserted with a patch of teflon or pericardiumadded on top of the suture line. The results were notsignificantly improved as there were two recurrencesin eight cases. Of the six cases with recurrence afterdirect suture, four had a ventricular septal defect of15 mm. and two of 20 mm. diameter. None of the12 cases with a defect of 10 mm. diameter or less hada recurrence after closure by direct suture (Table I).

TABLE ICORRELATION BETWEEN SIZE OF VENTRICULAR SEPTALDEFECT AND RECURRENCE AFTER CLOSURE BY DIRECT

SUTURE

Size of Defect No. of Recurrence(mm.) Cases No. %

10 12 015 17 4 2420 4 2 50

Total 33 6 18

In a 6-year-old boy with a ventricular septal defectof 15 mm. diameter a direct suture was carried out,but before closure of the sternum a murmur wasaudible. Blood samples showed an oxygen tension inthe right atrium of 51 mm. Hg and in the pulmonaryartery of 71 mm. Hg. Because closure was incompletethe patient was again connected to the extracorporealcirculation for insertion of a prosthesis. The totalperfusion time was 105 minutes and there was anuneventful recovery, no shunt, and a right ventricularpressure of 30 mm. Hg (55 mg. Hg before operation)at recatheterization one and a half years after opera-tion. After this experience a patch of teflon or dacronwas always fixed with isolated mattress sutures withouttension and buffered with teflon pearls in everyventricular septal defect of 10 mm. or more diameter.A patch was used in 19 ventricular septal defects withone recurrence, and in 28 cases of Fallot's tetralogywith one recurrence. For an analysis of the recurrencesthe cases of ventricular septal defect and Fallot'stetralogy are grouped together in 80 operations (Table

TA BLE IIRESIDUAL SHUNT AFTER OPERATION FOR VENTRICULAR

SEPTAL DEFECT AND FALLOT'S TETRALOGY

Technique No. of RecurrenceCases No.

Direct suture 25 4A 18Direct suture + second layer 8 2fPatch 47 2 4

Total 80 8 10

x

II). Of those, 44 were recatheterized or investigated atnecropsy, and the remainder were judged on clinicalgrounds alone. The recurrence rate was then found tobe 18% (6/33) in patients with direct closure, with orwithout a second layer of reinforcement with a teflonor pericardial patch. The recurrence was foundposteriorly where the direct suture included the baseof the septal tricuspid leaflet. At re-operation in fourpatients the thickened edges around the remaininghole could be used for a direct suture. As a com-parison, an incidence of 4%/ (2/44) was found when apatch was used.

In patients with large ventricular septal defectswithout any ridge between the pulmonary artery andthe aorta it was necessary to insert the bufferedmattress sutures from the aorta behind the base of theaortic cusp in two patients by the right atrial approachand in one patient from the pulmonary artery behinda pulmonary valve by the transventricular approach.These sutures from the aorta or pulmonary artery wereplaced over strips of dacron to prevent their cuttingthrough (Fig. 1). In one such patient, a 37-year-old

FIG. 1. The upper mattress sutures are placed through theroot of the aorta to the upper portion of the prosthesis.These sutures from the aorta or pulmonary artery mustbe placed over strips of dacron to prevent their cuttingthrough.

man with a huge heart of 940 ml./m.2 body surfaceand a right ventricular pressure of 85 mm. Hg, a25 to 35 mm. defect was closed by 21 mattress sutures,four of which were placed through the root of theaorta to the upper portion of the prosthesis. Thepressure immediately dropped to 25 mm. Hg, but thepatient needed a respirator for 30 days after theoperation. Two years later heart catheterizationshowed no shunt, a right ventricular pressure of30 mm. Hg. and a heart size of 480 ml./m.2 bodysurface and no symptoms.

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In this study there was an immediate decrease ofright ventricular pressure at the end of operation withan average of 30 mm. Hg (range 4-70 mm. Hg). Thenthere was a further decrease of right ventricularpressure during the first year after operation with anaverage of 20 mm. Hg (range 5-67 mm. Hg).

through the base of the septal tricuspid leafletabout 2 mm. from its insertion (Fig. 2). Then acontinuous suture of 3-0 silk can complete thefixation of the patch (Fig. 3).

HEART BLOCK

The direct suture technique had an incidence of 150,(five cases) total block (see Table II1). Two patientswith a ventricular septal defect complicated by a totalblock died two days and one year after operationrespectively. Two patients with Fallot's tetralogy diedafter a block complicating a direct suture closure, andthe third patient with situs inversus totalis is still alivethree years after operation but with heart block.

INCIDENCE OFTABLE III

BLOCK IN CORRELATION WITH THETECHNIQUE

Ventricular Fallot'sSeptal Defect Tetralogy

--. TotalNo. of Bok No. of BlcCases Block Cases Block

Direct suture 18 2 15 3 5 (15%)Patch 19 0 28 2 2 (4%)

Total 37 2 (5%) 43 5 (12%) 7

None of the 19 isolated ventricular septal defectswith a patch had a block, but one was present in twoof the 28 patients with Fallot's tetralogy. One ofthese died four days after operation in block; theother is still alive one year after operation. As theresting pulse rate of 50 could increase during a work-load of 300 kilopondmeters/min. to 100, it wasthought that pacemaker treatment was not indicated.One 4-year-old girl with Fallot's tetralogy treatedwith a patch in the ventricular septum and an out-flow prosthesis carried out on the narrow pulmonaryartery to its bifurcation had a total block treated bypacemaker for seven months when sinus rhythmreturned. Three years after surgery she was muchimproved. There was no shunt, but there was rightbundle branch block, a right ventricular pressure of98 mm. Hg, and narrow pulmonary arterial branches.

CONCLUSION

For the closure of ventricular septal defects apatch of dacron is preferred in all cases wherzthe aperture is of 10 mm. or more diameter.Isolated mattress sutures buffered with teflonpearls over the myocardium are placed in theposterior half of the circumference, leaving thelast 3 to 5 mm. free from the edges of the defect.The sutures are placed from the right atrial side

FIG. 2. Isolated mattress sutures buffered with teflon pear/sare placed in the posterior half of the circumference 3-4mm. from the edges of the muscular part of the defectand through the septal tricuspid leaflet about 2 mm. fromits insertion. In this way the bundle of His can be avoided.

FIG. 3. A continuous suture of 3-0 silk can complete thefixation ofthe dacron patch.

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THE TRANSATRIAL APPROACH

The transatrial approach was used in 19 consecutivecases with ventricular septal defects with two deathsand in another six with Fallot's tetralogy with onedeath. The patients who died were a 1-year-old boywith pulmonary hypertension of 80 mm. Hg andfibroelastosis, a 31-year-old man with pulmonaryhypertension of 90 mm. Hg and a huge heart of 1,020ml./m.2 body surface, and a 15-year-old cyanotic,Blalock-operated girl with Fallot's tetralogy. Theconclusions drawn from this experience are asfollows:For the transatrial approach it is necessary to

work on a flaccid heart. Therefore the aorta isclamped and the heart is packed in crushed ice. Aorticocclusion should not be continued for more than30 minutes, and preferably five minutes of coronaryperfusion is performed every 20 minutes. The defect isfirst palpated through the right auricular appendage.Cardiopulmonary bypass is started, the aorta is cross-clamped, and the heart is packed in crushed ice. Theright atrium is then opened from the inferior venacava to the incision in the auricular appendix 1 cm.from the atrioventricular groove. In eight of the 19cases of ventricular septal defect it was necessaryto make an incision 3 mm. from, and parallel to, thebase of the septal tricuspid leaflet to obtain a goodexposure of the defect. As a result of the jet effectof the shunt through the defect the septal tricuspidleaflet was always thickened and easy to close withan isolated or running suture without any evidenceof tricuspid insufficiency.

In two patients an additional correction for tricuspidinsufficiency had to be carried out. A 6-year-old girlwith a left-to-right shunt of 70% on the ventricular leveland a pulmonary hypertension with a right ventricularpressure of 125 mm. Hg was found to have a 20 to15 mm. diameter ventricular septal defect. An anomalywas found in that chordae tendineae from the septaltricuspid leaflet inserted on a papillary muscle in theleft ventricle through the septal defect (Fig. 4). Whenthe prosthesis was sutured in the defect one third ofthe septal tricuspid leaflet came down into the leftventricle through the posterior corner of the defect(Fig. 5). It was then necessary to suture the septaltricuspid leaflet remaining in the right ventricle to theedge of the anterior tricuspid leaflet to avoid a tri-cuspid insufficiency (Fig. 6). In retrospect it wouldhave been easier to make a slit in the prosthesis andplace the abnormal papillary muscle in its centre.The patient made an uneventful recovery withoutpalpable tricuspid insufficiency and with a drop inright ventricular pressure from 125 to 60 mm. Hg atthe same systemic pressure of 140 mm. Hg. One yearlater the patient was in excellent condition. The rightventricular pressure was 40/6 mm. Hg, the right atrialpressure 6 mm. and there were no signs of shunt, oftricuspid stenosis or of insufficiency.The second case of tricuspid insufficiency was a

15-year-old boy who had a tetralogy of Fallot; it was

FIG. 4. Chordae tendineae from the septal tricuspid leafletinserted on a papillary muscle in the left ventricle throughthe septal defect.

FIG. 5. One-third of the septal tricuspid leaflet came downinto the left ventricle through the posterior corner of thedefect when the prosthesis was sutured in place.

..<.>FIG. 6. To avoid a tricuspid insufficiency the septal tricus-pid leaflet remaining in the right ventricle was sutured to,the edge of the anterior tricuspid leaflet.

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not due to the repaired incision in the tricuspid leafletbut to rupture of a chorda tendinea due to traumaduring surgery. A significant tricuspid insufficiency waspalpated after decannulation. A second period of by-pass was instituted, and the edge of the septal tricuspidleaflet with the ruptured chorda was sutured to the edgeof the anterior tricuspid leaflet. A small insufficiencywas palpated at the end of the operation, and eightmonths later a mean pressure of 8 mm. Hg was foundin the right atrium with a systolic pressure wave of12 mm. Hg at a right ventricular pressure of 80 mm.Hg.

Regarding the transatrial approach in patients withtetralogy of Fallot it was necessary to make anincision in the tricuspid leaflet in five out of six cases.In one additional patient, a 57-year-old man, thetransatrial approach was first tried but gave a badexposure and had to be abandoned in favour of aventricular incision. As there was no ridge betweenthe pulmonary artery and the aorta the upper suturesto the patch were inserted through the base of thepulmonary artery.

In patients with tetralogy of Fallot an abnormaldistribution of the coronary arteries may increase therisk of a ventriculotomy, and in these circumstancesthe atrial approach could be used as an alternative.It should first be verified by angiocardiography thatno outflow prosthesis is needed. The ventricular septaldefect can usually be exposed through the base of theseptal tricuspid leaflet as easily as in an isolatedventricular septal defect. A pulmonary valvularstenosis is opened by a transverse incision in thepulmonary artery. The infundibular resection is moredifficult and time-consuming through the atrialapproach. Although only one of the six patients withFallot's tetralogy operated through the atrium died,a decrease in the right ventricular pressure to 35 mm.Hg was only obtained in one patient. In four patientsthe right ventricular pressure remained at 70 to 80mm. Hg and in the last patient it remained at 60 mm.Hg.

In conclusion the right atrial approach is favouredin all cases of isolated ventricular septal defects.

In cases of Fallot's tetralogy the atrial approachcan be used with a good result. There is a technicaldisadvantage during infundibular resection, however,which makes a ventriculotomy preferable for patientswith Fallot's tetralogy.

THE TRANS-AORTIC APPROACH

The trans-aortic approach for closure of a ventricularseptal defect has been used in two patients in whoman aortic insufficiency was the dominant lesion.

In a 46-year-old man a ventricular septal defect of10 mm. diameter was closed by direct suture mattresssutures placed through the base of the right sinus ofValsalva. A total aortic valve prosthesis was alsoinserted. The patient died from sepsis four monthslater when the ventricular septal defect was found tobe completely closed.

The second patient was a 20-year-old womanwith a defect of 20 to 15 mm. diameterwhich was closed with a patch through the rightatrium. A concomitant severe aortic insufficiencywas treated two years later with a Starr-Edwardsball valve prosthesis when a 5x5 mm. defect causedby suture insufficiency in the upper portion of thepatch was found. This defect was closed by a patch ofaortic valvular tissue turned down into the leftventricle and sutured to the old dacron patch (Fig.7). The cuff of the ball valve prosthesis was then usedas a reinforcement (Fig. 8). The patient made anuneventful recovery.

COMPLICATED CASES

VENTRICULAR SEPTAL DEFECT WITH PATENT DUCTUSARTERIOSUS In patients under the age of 2 years witha ductus as well as an isolated ventricular septal defectthe ductus has been divided at a first operation andthe ventricular septal defect closed at a later date.

In older patients a one-stage procedure has beenused. The patient is placed on total cardiopulmonary

FIG. 7. The remaining part ofaortic valvular tissue was usedas a patch turned down and sutured to the old dacronpatch.

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',M.I

FIG. 8. Fixation of the cuff of the ball valve prosthesisas a second layer over the ventricular septal defect.

bypass and the body temperature is brought down to3Ut to 25i C. Cule cLrculation is then completelyarrested for five to 10 minutes, the main pulmonaryartery is opened with a longitudinal incision, whichmay be extended into the left pulmonary artery, andthe ductus is closed from the inside of the pulmonaryartery with a running suture. If more time is neededthe circulation is continued with the heart/lungmachine while the ductus is closed with the surgeon'sfingertip. When an undiagnosed ductus has beenfound during open heart surgery the pulmonary arteryis opened and the ductus is occluded with a fingerwhile the temperature is brought down so that thecirculation can be arrested.

In this series the combined procedures were carriedout twice. In a 4-vear-old boy with a huge heart of980 ml./m.2 body surface the circulation was arrestedfor 8 min. at 230 C. for closure of the ductus. Thena lOx 10 mm. defect was closed with a patch fromthe right atrium. The time on bypass was 42 minutes.Recovery was uneventful. After one month the hearthad decreased to 720 ml./m.2, after two months to440 ml./m.2, and after one year to 420 ml./m.2. Thepulmonary artery pressure was 50 mm. Hg beforeand 30 mm. Hg after one year when no shunt was

found at catheterization.The second patient was a 38-year-old woman in

whom a ductus was found after opening the heart.The circulation was arrested for 2 min. when the pul-monary artery was opened and the ductus was

occluded by a finger. During 6 min. of perfusion thetemperature was brought down to 29° C. and thecirculation was again arrested for 5 min., when fiveisolated mattress sutures from the inside of thepulmonary artery closed the ductus. Then a 20 to15 mm. diameter ventricular septal defect was closedwith a patch through the right atrium after an incisionin the septal tricuspid leaflet. The patient recoveredand the heart size decreased from 840 ml./m.2 to550 ml./m.2. The right ventricular pressure beforeoperation was 100 mg. Hg, at the end of operation55 mg. Hg, and one and a half years later only 33 mm.

Hg when no shunt could be demonstrated at catheteri-zation.

VENTRICULAR SEPTAL DEFECT WITH PULMONARY VAL-

VULAR STENOSIS Cases combined with pulmonaryvalvular stenosis and a left-to-right shunt areapproached with two incisions, transatrial for theventricular septal defect and a transverse incision inthe pulmonary artery. In pulmonary valvular stenosisit is nearly always necessary to begin by freeing thefused commissures from the arterial wall before twoincisions are made in the commissures. This techniquewas used in a 21-year-old man with a left-to-rightshunt of 4-7 litres/min. and a right ventricular pressureof 100 mm. Hg. The pressure immediately decreasedto 30 mm. Hg and no shunt was detected two yearsafter operation.

VENTRICULAR SEPTAL DEFECT AND AORTIC INSUFFICIENCYSmaller defects are approached through the aorticincision at the same time as a total valve prosthesisis inserted. This was done in two patients.

If the shunt and defect are big, a two-stageprocedure with closure of the ventricular septal defectthrough the right atrium is performed at the firstoperation. The valve prosthesis is then introduced ata second stage. This was successfully done in a 20-year-old woman with a defect of 20 to 15 mm.diameter. The aortic insufficiency was not improvedafter the first stage, and a ball valve prosthesis wasinserted two years later.An attempt to correct the aortic insufficiency

through a 25 to 15 mm. diameter ventricular septaldefect by bicuspidalization in a 15-year-old girl wasnot successful. The insertion of a ball valve prosthesisin the aortic orifice through a large ventricular septaldefect is theoretically possible, but coronary perfusionwould be impossible without aortotomy.A ventricular septal defect was combined with

infundibular stenosis and pulmonary valvular stenosisas well as a severe aortic insufficiency and a hugeheart of more than 700 ml./m.2 body surface in one15-year-old and one 19-year-old patient. An aorticvalvular prosthesis was inserted as well as a patch inthe ventricular septal defect and a right infundibularresection and pulmonary valvular commissurotomyduring slightly more than 2 hours' perfusion; in bothpatients there was a good local result. One patientdied of a brain embolism from a thrombosis at thebase of a teflon aortic prosthesis; the other, in whoma ball valve aortic prosthesis had been used, diedfrom circulatory failure. It seems that a completecorrection of such a complicated lesion in one stageis too extensive an operation. Further experience withone successful case of closure of a ventricular septaldefect in one stage and the introduction of a ballvalve prosthesis at a later date in a 20-year-oldwoman speaks in favour of a two-stage procedure.VENTRICULAR SEPTAL DEFECT COMBINED WITH A

RUPTURED SINUS OF VALSALVA ANEURYSM In a 32-year-old man with a huge heart of 800 ml./m.2, a

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ruptured sinus of Valsalva aneurysm was diagnosedand verified at cardiotomy through the right ventricle.A high 7 mm. diameter ventricular septal defect wasalso found and closed by direct suture. Catheteriza-tion one year later showed no shunt, the pulmonaryartery pressure had decreased from 40 mm. Hg to23 mm. Hg, and the working capacity had increasedfrom 400 to 800 kilopondmeters/minute.

TRAUMATIC VENTRICULAR SEPTAL DEFECT A 15-year-old boy had been treated for a pulmonary valvularstenosis by a transventricular dilatation in 1954. Atoperation severe bleeding was noted when the dilatoremerged outside the heart at the left of the root ofthe pulmonary artery. A traumatic ventricular septaldefect had been caused as well as a lesion of theleft descending coronary artery which was ligated.Later on a large anterior infarction developed andthe pulmonary valvular stenosis remained. Directsuture of the ventricular septal defect and commis-surotomy of the pulmonary valve through the arterywas performed. There was failure of the circulationwhich had to be supported by massage before thepatient was connected to the heart/lung machine, andthe patient did not survive the operation.

In a 16-year-old girl with an isolated infundibularstricture a right transventricular dilatation in 1955caused a traumatic ventricular septal defect (Fig. 9).The right ventricular pressure remained at 136 mm.Hg. At operation the infundibular stricture was re-sected and a 15 mm. diameter traumatic ventricular

FIG. 9. Trauniatic ventricular septa! defect in a patientwith isolated infundibular stricture.

septal defect with fibrotic edges was closed by directsutures over teflon strips. Later a second small defectin the membranous septum of the usual type was alsofound and closed by direct suture. The right ventricu-lar pressure decreased from 136 mm. Hg to 25 mm.Hg at the end of operation. The patient made an un-eventful recovery.

RECURRENT VENTRICULAR SEPTAL DEFECT Four casesof recurrent ventricular septal defect after directsuture were easily closed by direct sutures through athickened and fibrotic rim. The recurrent defect wasalways found posteriorly at the edge of the septaltricuspid leaflet. Recovery was uneventful in all fourpatients. Excessive post-operative bleeding wasavoided by delayed closure. In all re-operations theclosure of the wound was delayed for one to twohours until all oozing had ceased.

SUMMARY

The surgical technique of closure of ventricularseptal defects in 80 cases (37 cases of isolateddefects and 43 cases of tetralogy of Fallot) isdiscussed in the light of the follow-up results.The use of a patch for closure has reduced theincidence of recurrence to 4 %, compared with 18 0/,/,when direct suture was performed. The incidenceof heart block also decreased from 15 %, whendirect suture was used, to 4% with a patch. Thetransatrial approach is preferred for isolatedventricular septal defects; the ventricularapproach is preferred for cases with tetralogy ofFallot. In cases combined with aortic insufficiencyonly small defects are closed through the aorta.Larger defects are closed in the usual way at afirst stage operation, and a total valve prosthesisis introduced at a second operation. There was anoperative mortality of 6% in isolated ventricularseptal defects, compared with 27o% in cyanoticpatients with tetralogy of Fallot.

REFERENCES

Bjork, V. 0. (1964). The transatrial approach to ventricular septaldefect. J. thorac. cardiovase. Surg., 47, 178.

Cleland, W. P., and others (1958). The treatment of ventricular septadefect. Brit. med. J., 2, 1369.

Cooley, D. A. (1959). Current status of the surgical treatment ofventricular septal defect. Dis. Chest, 35, 651.

Kay, J., and others (1960). The surgical repair of high pressure ven-tricular septal defect through the right atrium. Surgery, 48, 65.

Kirklin, J. W., HIarshbarger, H. G., Donald, D. E., and Edwards.J. E. (1957). Surgical correction of ventricular septal defectAnatomic and technical considerations. J. thorac. Surg., 33, 45.

Lillehei, C. W., Cohen, M., Warden, H. E., Ziegler, N. R.,and Varco,R. L. (1955). Results of direct vision closure of ventricularseptal defects in eight patients by means of controlled crosscirculation. Surg. Gvnec. Obstet., 101, 446.

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