Primary Treatment for Ventricular Septal Defect (VSD)
Surgical closure is the primary treatment for patients with VSD who have left ventricular volume overload and hemodynamically significant shunts (Qp:Qs ≥1.5:1), provided pulmonary artery systolic pressure is less than 50% systemic and pulmonary vascular resistance is less than one-third systemic. 1
Indications for VSD Closure
The decision to close a VSD depends on several key factors:
Strong Indications for Closure (Class I):
- Qp:Qs ratio ≥2.0 with clinical evidence of LV volume overload 1
- Qp:Qs ratio ≥1.5:1 with LV volume overload and hemodynamically significant shunts 1
- History of infective endocarditis 1
- PA systolic pressure <50% systemic and pulmonary vascular resistance <1/3 systemic 1
Reasonable to Consider Closure (Class IIa):
- Qp:Qs >1.5 with pulmonary artery pressure <2/3 systemic and PVR <2/3 systemic 1
- Worsening aortic regurgitation caused by perimembranous or supracristal VSD 1
- LV systolic or diastolic failure with Qp:Qs >1.5 1
May Consider Closure (Class IIb):
- Qp:Qs ≥1.5:1 when PA systolic pressure is ≥50% systemic and/or pulmonary vascular resistance is >1/3 systemic 1
Contraindications to Closure (Class III: Harm):
- Severe pulmonary arterial hypertension with PA systolic pressure >2/3 systemic 1
- Pulmonary vascular resistance >2/3 systemic 1
- Net right-to-left shunt (Eisenmenger syndrome) 1
Treatment Approach Based on VSD Type
Perimembranous VSD (80% of cases) 2:
- Surgical closure with patch material (Dacron, Gore-Tex) is the standard approach
- Careful assessment for aortic valve prolapse which may require additional intervention
Supracristal VSD (13% of cases) 2:
- Surgical closure recommended, especially when associated with aortic regurgitation 1
Muscular VSD (4% of cases) 2:
- Surgical closure for large defects
- Percutaneous device closure may be considered, particularly for mid-muscular VSDs 3, 4
- Hybrid approach (perventricular) for apical or anterior defects difficult to access surgically 4
Inlet VSD (3% of cases) 2:
- Surgical closure with attention to avoid damage to conduction system
Surgical Outcomes and Considerations
Modern surgical outcomes are excellent:
- Mortality rate is very low (0.5-3%) 2, 5
- Risk of complete heart block is minimal with proper technique 2
- Median hospital stay is 5-6 days 2, 5
- Long-term outcomes show 99.5% of patients are asymptomatic from a cardiac standpoint at follow-up 2
Special Considerations
Pulmonary Hypertension:
- Patients with elevated pulmonary vascular resistance require careful evaluation
- In borderline cases with elevated PVR, some surgeons leave a small atrial communication to serve as a pop-off valve 6
- Postoperative management may include pulmonary vasodilators 6
Timing of Intervention:
- Early repair is recommended to prevent development of pulmonary vascular obstructive disease 3
- For symptomatic infants with heart failure, repair is typically performed within the first year of life 5
Follow-up After VSD Closure:
- Adults with residual heart failure, shunts, PAH, aortic regurgitation, or outflow tract obstruction should be seen annually at an adult congenital heart disease center 1
- Adults with small residual VSD and no other lesions should be seen every 3-5 years 1
Pitfalls and Caveats
- Failure to recognize associated lesions (aortic valve prolapse, double-chambered right ventricle)
- Misinterpreting VSD jet as tricuspid regurgitation jet, leading to incorrect diagnosis of pulmonary hypertension
- Delaying intervention in patients with significant shunts, risking development of irreversible pulmonary vascular disease
- Attempting closure in patients with Eisenmenger physiology, which is contraindicated and harmful
Remember that surgical expertise is critical - VSD closure operations should be performed by surgeons with training and expertise in congenital heart disease 1.