What are the treatment options for septal defects in the heart?

Treatment Options for Septal Defects in the Heart

The treatment of septal defects in the heart depends on the type of defect, its size, and associated hemodynamic consequences, with options including surgical repair, transcatheter device closure, and medical management. The approach varies based on whether the defect is atrial (ASD) or ventricular (VSD), and whether it occurred congenitally or as a complication of myocardial infarction.

Atrial Septal Defects (ASDs)

Indications for Intervention

• Intervention is indicated for patients with significant shunts causing right ventricular volume overload, regardless of symptoms 1
• Closure should be performed even in asymptomatic patients, typically at 4-5 years of age in children 2
• For adults, closure is recommended at the time of presentation 2

Treatment Options for ASDs

1. Device Closure

   • First-line treatment for secundum ASDs when anatomically suitable 1
   • Requirements:
     • Defect diameter <38mm
     • Sufficient rim of 5mm (except towards the aorta)
     • Approximately 80% of secundum ASDs are amenable to device closure 1
   • Post-procedure care:
     • Antiplatelet therapy with low-dose aspirin for at least 6 months 1
     • For older children and adults, additional anticoagulant may be considered for 3-6 months 1

2. Surgical Closure

   • Indicated for:
     • Primum ASDs
     • Sinus venosus defects
     • Coronary sinus defects
     • Large secundum ASDs not suitable for device closure
   • Excellent outcomes with low mortality and morbidity 3
   • Most patients achieve NYHA class I status post-repair 3

Ventricular Septal Defects (VSDs)

Congenital VSDs

1. Device Closure

   • Available for certain types of VSDs
   • Procedural anticoagulation: 100 U/kg UFH (up to 5000-U maximum) 1
   • Post-procedure: Low-dose aspirin for at least 6 months 1

2. Surgical Repair

   • Standard approach for most VSDs not amenable to device closure
   • Excellent outcomes with current surgical techniques 4

Post-Myocardial Infarction VSDs

1. Emergency Surgical Repair

   • Urgent surgery is indicated even in hemodynamically stable patients 1
   • Pre-operative coronary angiography should be performed 1
   • CABG grafts inserted as necessary during repair 1
   • Hospital mortality after surgery ranges from 25-60%, with 95% of survivors achieving NYHA class I or II 1

2. Temporizing Measures Before Surgery

   • Intra-aortic balloon counterpulsation provides the most effective circulatory support 1
   • Pharmacological support with vasodilators (IV nitroglycerin) if no cardiogenic shock 1, 5
   • Inotropic agents (dopamine and/or dobutamine) 1
   • Ventilatory support if inadequate oxygenation 1

3. Percutaneous Closure

   • Emerging option that might allow initial hemodynamic stabilization 1
   • Limited experience and common residual shunts 1
   • Further technical developments and trials needed 1

Diagnostic Evaluation

Echocardiography

• Transthoracic echocardiography (TTE) is the key diagnostic technique 1
• For ASDs:
  • Identifies defect type, size, and location
  • Assesses right ventricular volume overload
  • Evaluates pulmonary artery pressure
• For VSDs:
  • Locates defect and assesses size
  • Evaluates left-to-right shunt with color Doppler
  • Estimates right ventricular pressure

Transesophageal Echocardiography (TEE)

• Essential for:
  • Accurate diagnosis of sinus venosus defects 1
  • Evaluation of secundum ASDs before device closure 1
  • Intra-operative guidance during surgical repair 1
  • Guidance during device closure procedures 1

Additional Imaging

• CMR and CT can be alternatives if echocardiography is insufficient 1
• Cardiac catheterization required in cases of high pulmonary artery pressure to determine pulmonary vascular resistance 1

Special Considerations

Pulmonary Vascular Resistance (PVR)

• Closure contraindicated in patients with Eisenmenger physiology 1
• Patients with PVR ≥5 Wood units but <2/3 SVR may be considered for intervention if net left-to-right shunt exists 1

Post-Infarction Complications

• Risk factors for ventricular septal rupture: first MI, anterior infarction, elderly, female, hypertension during acute phase 1
• Poor prognostic factors: cardiogenic shock, posterior location, right ventricular dysfunction, advanced age 1

Long-term Follow-up

• Regular follow-up echocardiography recommended to assess:
  • Residual shunts
  • Device position and endothelialization
  • Ventricular function
  • Pulmonary artery pressure

The management of septal defects has evolved significantly with advances in both surgical techniques and transcatheter interventions, offering excellent outcomes for most patients when appropriate treatment strategies are implemented.