From the Guidelines
The management of congenital ventricular septal defects (VSDs) should be guided by the most recent guidelines, which recommend surgical closure for large VSDs (Qp/Qs ≥ 2.0) and for those with a history of infective endocarditis, as stated in the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1. The approach to managing VSDs involves evaluating the size of the defect and the presence of symptoms, with small VSDs (less than 3mm) often closing spontaneously and requiring only monitoring with regular echocardiograms every 1-2 years if asymptomatic.
- For moderate VSDs (3-5mm), more frequent monitoring every 6-12 months is recommended, with attention to signs of heart failure or pulmonary hypertension.
- Large VSDs (greater than 5mm) usually require surgical closure, typically between 3-6 months of age, to prevent complications.
- Medical management before surgery may include diuretics like furosemide (1-2mg/kg/day divided twice daily) and spironolactone (1-3mg/kg/day divided twice daily) for heart failure symptoms, and ACE inhibitors such as enalapril (0.1mg/kg/day initially, increasing gradually) for afterload reduction, as suggested by the ACC/AHA 2008 guidelines for the management of adults with congenital heart disease 1. The management approach is guided by the pathophysiology of VSDs, where larger defects cause significant left-to-right shunting, volume overload of the pulmonary circulation, and potential development of pulmonary hypertension if left untreated, highlighting the importance of timely intervention to improve morbidity, mortality, and quality of life outcomes.
- Nutritional support is crucial as infants with significant VSDs often have increased metabolic demands and feeding difficulties; high-calorie formulas or supplementation may be necessary.
- Antibiotic prophylaxis is no longer routinely recommended for most VSDs but may be considered in specific high-risk cases, as noted in the 2018 AHA/ACC guideline 1. Surgical closure of VSDs should be performed by surgeons with training and expertise in congenital heart disease, as recommended by the ACC/AHA 2008 guidelines 1.
From the Research
Diagnosis and Management of Congenital VSD
- Ventricular septal defects (VSDs) account for up to 40% of all congenital cardiac malformations, with a broad range of anomalies and varying presentation, symptoms, and natural history 2.
- The management of VSDs depends on the size and anatomical associations of the anomaly, patient's age, and local diagnostic and interventional expertise 2.
- Echocardiography is a crucial tool for diagnosing and characterizing VSDs, providing accurate anatomic and hemodynamic evaluation to determine the need for surgical or transcatheter-based intervention 3.
Treatment Options for VSD
- Surgery remains the treatment of choice for VSDs, but transcatheter techniques have become an alternative for closing various types of VSDs 4.
- Transcatheter closure of selected VSDs appears to be an effective and safe method of treatment, with high rates of successful interventions and a low incidence of complications 4.
- Percutaneous transcatheter closure of VSDs has been attempted in patients who are not candidates for operative management, with varying degrees of success 5.
Types of VSD
- There are four major types of VSDs: perimembranous, muscular, outlet, and inlet VSDs, each with distinct characteristics and management considerations 3.
- Understanding the anatomy and classification of VSDs is essential for determining the best course of treatment and management 3.
Current Management Strategies
- Current management strategies for VSDs vary greatly depending on the location, clinical presentation, associated lesions, and natural history of the defect 6.
- The choice of treatment depends on the individual patient's needs and circumstances, with a range of options available, including surgical repair, transcatheter closure, and medical management 2, 4, 6.