Invited Commentary Muscular Ventricular Septal Defects in Small Patients—Invited Commentary

In this issue of the Journal, Fouilloux and colleagues describe their excellent results using the Amplatzer muscular ventricular septal defect (VSD) device for echocardiography-guided per-ventricular closure of muscular ventricular septal defects with-out cardiopulmonary bypass. As the authors note, this technique is very similar to the technique reported by Bacha et al.1 Placement of a perventricular device is a particularly attractive option in small children (<6 kg) due to the vascular access and delivery device challenges inherent in the transvas-cular approach. Since percutaneous, transvascular device deliv-ery is often not an option in smaller infants, alternative approaches must be considered. Other options include perven-tricular device closure, palliation with a pulmonary artery banding, or surgical closure through the standard right atrial approach or through a ventriculotomy