**8.4 Hybrid approach**

In rare cases, such as small infants with hemodynamically significant muscular VSDs a hybrid "perventricular" approach has been utilized without placing patient on cardiopulmonary bypass; this procedure is performed under TEE guidance. In these cases, access is obtained through a median sternotomy or subxiphoid incision. The device delivery sheath is inserted under TEE guidance from right to left ventricle. The success rate of closure with these devices is reported from 82 to 100% in different studies. Complications include arrythmias, device malposition or missing additional defects. Unsuccessful implantations are converted to conventional open-heart surgical repair [32]. These percutaneous perventricular approach has also been described for successful closure of subarterial VSDs in a small number of patients [39].

Detailed description of percutaneous and perventricular device closures of VSDs is beyond scope of this chapter; the interested is referred elsewhere [32].
