Figure Legends
Figure 1: Schematic diagram of the location of defects in the apical
muscular septum.
Figures 2A, 2B: Panel A: Transthoracic echocardiographic image with
color flow showing multiple defects (red arrows) in the apical muscular
septum (asterisk) which demonstrate a left to right shunt from left
ventricle (LV) to right ventricle (RV). Panel B: Left ventricular
angiogram in left anterior oblique view with cranial angulation
demonstrating multiple oblique defects (asterisks) representing a
Swiss-cheese septum.
Figures 3A-3F: Volume rendered (A) and oblique coronal (B) image showing
the ventricular septum en-face and revealing the presence of multiple
defects (various colored arrows). Short axis images at the mid
ventricular level (C and D), at the ventricular apex (E) and four
chamber image (F) profile the various defects (corresponding colored
arrows).
Figures 4A-4F: Volume rendered (A) and oblique coronal (B) image showing
the ventricular septum en-face and demonstrating the presence of
multiple defects (various colored arrows). Oblique axial images at
various levels (C to F) profile the respective defects (corresponding
colored arrows).
Figures 5A-5F: Surgical photograph showing step-by-step passage of a
thick No.3 black braided SUTUPAK silk (Ethicon, Johnson and Johnson Pvt.
Ltds., USA) ligature (L) through the additional muscular ventricular
septal defect (VSD) in a child with multiple discrete muscular septal
defects. 5A: shows the small aorta (AO), distended right ventricle (RV),
and tense hypertensive pulmonary artery (PA); 5B, 5C: a right angle
forcep (F) is passed through the additional ventricular septal defect,
and kissed against a DeBakey forcep which is inserted through the larger
VSD. The tip of silk ligature is grasped and looped through the
additional septal defect. Traction on the silk ligature facilitated
exposure of the margins of septal defect; 5D, 5E: two ventricular septal
defects are closed separately using Dacron knitted polyester patches
(BAARD® SAUVAGE® Filamentous, BARD peripheral vascular Inc, Temple, AZ,
USA) and 5-0 interrupted pledgeted mattress sutures; 5F: shows the
separately closed ventricular septal defect.
Figures 6A, 6B: Schematic drawing of Kitagawa’s technique of insertion
of an oversized patch on the left ventricular side of the defect.
Figures 7A, 7B: Mace’s technique of surgical closure of the Swiss-cheese
septum using a single large patch on the right ventricular side with
intermediate fixation to prevent septal bulging.
Figure 8: Ootaki’s technique of sandwiching the apical defects between
the two polyester felt patches.
Figure 9: Kitagawa’s technique of closure of multiple apical defects,
sandwiching the septum with the anterior wall of the ventricle.
Figures 10A-10C: Surgical closure of apical defects through an apical
right ventriculotomy.
Figure 11: Surgical approach to apical defects through a modified apical
left ventriculotomy.
Figure 12: Wu’s two-patch and right ventricular apex exclusion technique
of repair of the Swiss-cheese septum.