A ventricular septal defect (VSD) with an atrial septal defect (ASD) is a common type of complex congenital heart disease (CHD). Surgical repair under general anesthesia with cardiopulmonary bypass has been proven effective for treating VSD combined with ASD. Moreover, an ultrasound-guided device closure technique with zero radiation has been developed, in addition to percutaneous intervention guided by digital subtraction angiography [1, 2], which allows for percutaneous and percardiac approaches to closure, offering advantages such as reduced trauma, faster recovery, and higher success rates [3, 4, 5, 6]. However, until recently, fewer reports have been published on percardiac or percutaneous device closures of VSD combined with ASD. Therefore, this study aimed to provide a one-stop closure strategy for patients with VSD combined with ASD guided by transesophageal echocardiography (TEE) via percardiac (peratrial approach, lower mini-sternotomy approach, or left parasternal approach) or combined with percutaneous approaches, and to evaluate its benefits and clinical efficacy.

Currently, surgery with cardiopulmonary bypass support remains the most effective strategy for treating VSD with ASD. However, due to issues such as extensive trauma, large scars, and prolonged postoperative hospitalization, an increasing number of surgeons are turning to research on minimally invasive interventional surgical methods [7, 8, 9, 10, 11, 12].

Recently, percutaneous intervention techniques have demonstrated high success rates and low complication rates in treating isolated VSD or ASD [13, 14, 15]. However, this technique has certain limitations depending on the age, weight, and specific anatomical characteristics of the patient and may not be suitable for all types of cardiac defects.

Specifically, for treating PmVSD, patients typically need to be at least 2 years old, weigh $\ge$10 kg, and have an AV distance of $\ge$2 mm [15, 16, 17]. When treating ASD, percutaneous intervention techniques require an ASD edge distance from the coronary sinus, superior and inferior vena cava, and pulmonary vein openings to be at least 5 mm and a distance from the atrioventricular valve of at least 7 mm [18, 19, 20]. Considering these issues, various minimally invasive surgical methods developed in recent years have expanded the scope of surgical applications [7, 8, 12, 21]. Among them, the TEE-guided minimally invasive percardiac closure technique has been widely used and has become one of the primary methods for isolated CHD.

For VSD combined with ASD patients, especially infants, early intervention may be required due to the potential severe pulmonary congestion. Although percutaneous intervention techniques have been widely applied, they may not be the safest and most effective solution for certain cases, such as those with DCVSD, mVSD at the apex, a large VSD that is not easily occluded, or those associated with mild aortic valve prolapse. With an increase in the number and duration of catheter insertions, there is a corresponding increase in the risks of atrioventricular block, procedural time, and radiation dose [11, 22, 23, 24]. Additionally, younger patients may face challenges in using intervention catheters due to limitations in their vascular access [23, 24].

To date, there are fewer reports on percardiac closure for VSDs combined with ASDs [25, 26]. For percardiac closure of a VSD combined with an ASD, our methods contain the peratrial approach, lower mini-sternotomy perventricular approach, and left parasternal–perventricular approaches. For moderately sized PmVSDs with favorable edge conditions and a shunt direction towards the right atrium and the anterior wall of the right ventricle, our center uses the peratrial approach with a 1.5–3 cm incision (Fig. 7A) through the right chest to the right atrium for VSDs. This method resulted in satisfactory therapeutic outcomes and follow-up results without impairing right ventricular function. For PmVSDs that are too small (2 mm) or too large ($>$7 mm), with an AV distance less than 2 mm, without a membranous aneurysm, multiple defects, or with shunt streams close to the septum, and apical mVSDs, the peratrial approach for VSD closure may be relatively challenging. Due to the favorable orientation of the right ventricular approach for eccentric positioning of the occluder relative to the aortic valve and apex, our center tends to select a device closure procedure through a lower mini-sternotomy perventricular approach for such patients (Fig. 7B). Meanwhile, for patients with DCVSDs, the perventricular approach may make achieving the necessary perpendicular angle to the defect difficult unless the lower mini-sternotomy incision is extended upward [27]. In such cases, our center tends to choose the left parasternal–perventricular approach (Fig. 7C).

Fig. 7.

Photographs demonstrate that postoperative scars have significantly faded over several years. (A) Right chest small incision (peratrial approach). (B) Lower sternotomy small incision (lower mini-sternotomy perventricular approach). (C) Left parasternal small incision (left parasternal–perventricular approach). Note: the arrow in each panel indicates the postoperative scar.

The main approaches for ASDs are percutaneous and transthoracic device occlusions. For patients with an ASD who are at least 2 years old and weigh at least 10 kg, if the defect margins are suitable for occlusion (i.e., the distance between the ASD edge and the coronary sinus, superior vena cava, inferior vena cava, and pulmonary vein is at least 5 mm, and the distance from the atrioventricular valve is at least 7 mm, with an ASD diameter of less than 25 mm), the first option is percutaneous approach. However, for ASD patients with multiple defects or a short distance to the superior or inferior vena cava edges, or for ASD who are younger than 2 years old or weigh less than 10 kg, if they have severe symptoms or right ventricular volume overload, the peratrial approach may be safer [7]. In short, if the ASD is too large, numerous, or has poor edge conditions, the peratrial approach is chosen; if the ASD is small with favorable edge conditions, the percutaneous approach is preferred.

Due to the anatomical characteristics of VSDs, completely avoiding the RS immediately after surgery is difficult. In this study, the RS of a VSD were all approximately 1 mm and completely disappeared during follow-up. The VSD occluder may affect the function of the aortic and tricuspid valves, while the ASD occluder may affect the mitral valve, leading to regurgitation. The peratrial approach for VSD occlusion and the perventricular approach for ASD occlusion involves passing the delivery system through the tricuspid valve, which may increase the risk of valve injury. If moderate or greater regurgitation develops, immediate device replacement or adjustment should be considered. In this study, three patients experienced mild tricuspid regurgitation, while two cases of mild aortic valve regurgitation were noted, and one patient developed mild mitral regurgitation postoperatively; all disappeared during the follow-up. The most common arrhythmia is a newly developed incomplete or complete right bundle branch block after occluder implantation. In this study, incomplete right bundle branch block developed in 3 of 40 patients postoperatively and disappeared within 3 months of follow-up. One patient who underwent the perventricular approach experienced two episodes of transient sinus bradycardia postoperatively within 24 hours, which did not recur before discharge or during subsequent follow-up, likely related to vagal nerve stimulation. Gentle intraoperative handling, selecting an appropriate occluder, and avoiding excessive repeated attempts during the operation could help reduce the incidence of complications.

The percardiac/percutaneous approaches under TEE guidance do not require digital subtraction angiography or contrast agents, reducing equipment needs and costs, and the technique is easy to master. Furthermore, the percardiac approach is not restricted by age, weight, or vascular conditions, has a shorter delivery path for the occluder, and offers more convenient operation and greater flexibility in surgical planning. However, these approaches are not suitable for all types of VSD or ASD. Specifically, for complex cases, traditional surgery is still considered the safest treatment option to ensure patient safety and surgical outcomes. Despite the advantages of TEE, this technique necessitates general anesthesia and tracheal intubation for assisted breathing. The percardiac approach also carries risks such as scarring, pleural effusion, pneumothorax, sternal deformity, or bleeding.

This study confirms that under TEE guidance, selecting different approach combinations for one-stop device closure of a VSD combined with an ASD is safe and feasible. This treatment plan, which applies different combinations of device closure techniques based on patient-specific conditions, does not increase the risk of complications and ensures a high success rate. Tailoring the surgical approach to the specific anatomical conditions of VSDs and ASDs in each patient, utilizing optimized techniques such as percardiac or combined percutaneous device closure under TEE guidance, offers several advantages: patient-specific treatment, high success rate, minimal trauma, small scars, no radiation exposure, and broad applicability, thereby providing new perspectives and valuable reference for clinical practice.

CHD, Congenital Heart Disease; TTE, Transthoracic Echocardiography; VSD, Ventricular Septal Defect; ASD, Atrial Septal Defect; PmVSD, Perimembranous Ventricular Septal Defect; mVSD, Muscular Ventricular Septal Defect; DCVSD, Doubly Committed Juxtaarterial Ventricular Septal Defect; DDS, Direct Delivery System; PADS, Probe-assisted Delivery System; RS, Residual Shunt; LVEDD, Left Ventricular End-Diastolic Diameter.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

JS, YS, and HL contributed to the conception and design of the study. JS, YS, SS, and HM contributed to data acquisition and interpretation. JS and HM were responsible for data analysis. JS, YS, SS, and HL were involved in drafting the manuscript and critical revision for important intellectual content. All authors reviewed and approved the final version of the manuscript, contributed to editorial revisions, and agree to be accountable for all aspects of the work, ensuring its accuracy and integrity.

The study was carried out in accordance with the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Qianfoshan Hospital (Protocol No. S747). Informed consent was obtained from each adult patient or the legal guardians of minors.

This research received no external funding.

The authors declare no conflict of interest.