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.