What are the treatment options for Ventricular Septal Defect (VSD) closure?

Treatment Options for Ventricular Septal Defect (VSD) Closure

Surgical closure is the recommended treatment for adults with VSDs that have hemodynamically significant shunts (Qp:Qs ≥1.5:1) and evidence of left ventricular volume overload, provided that pulmonary artery systolic pressure is less than 50% systemic and pulmonary vascular resistance is less than one-third systemic. 1

Patient Selection Criteria for VSD Closure

Indications for VSD Closure:

• Hemodynamically significant shunt (Qp:Qs ≥1.5:1) with left ventricular volume overload 1, 2
• Worsening aortic regurgitation caused by VSD (particularly perimembranous or supracristal VSDs) 1
• History of infective endocarditis caused by VSD 1, 2
• Large VSDs with symptoms of heart failure 3

Contraindications for VSD Closure:

• Severe pulmonary arterial hypertension (PAH) with PA systolic pressure >2/3 systemic 1, 2
• Pulmonary vascular resistance >2/3 systemic 1, 2
• Net right-to-left shunt (Eisenmenger syndrome) 1, 2

Diagnostic Evaluation Before VSD Closure

• Echocardiography: Essential for determining VSD size, location, shunt magnitude, and associated lesions 2
• Cardiac catheterization: Recommended when pulmonary hypertension is suspected or noninvasive data are inconclusive 2
• Assessment of Qp:Qs ratio, pulmonary artery pressure, and pulmonary vascular resistance 1

Treatment Approaches Based on VSD Type

1. Perimembranous VSDs

• Preferred treatment: Surgical closure 3, 4
• Approach: Median sternotomy with cardiopulmonary bypass 2
• Access via right atriotomy or right ventriculotomy 2
• VSD closure with patch material 2
• Caution: Percutaneous device closure has higher risk of complete heart block (1-5%) 5

2. Muscular VSDs

• Options include:
  • Surgical closure: Standard approach for large defects 2
  • Percutaneous device closure: Excellent option beyond infancy with low morbidity 5, 4
  • Hybrid perventricular approach: Particularly useful for apical or anterior VSDs difficult to access surgically 5
• Device: Amplatzer Muscular VSD Occluder is FDA-approved for muscular VSDs 4

3. Supracristal VSDs

• Preferred treatment: Surgical closure 3, 4
• Higher urgency when associated with aortic valve prolapse to prevent progressive aortic regurgitation 1

4. Inlet VSDs (part of atrioventricular septal defects)

• Preferred treatment: Surgical repair 4

Special Considerations

Small VSDs:

• Small restrictive defects without complications may be managed conservatively 1
• Long-term survival rate of 96% at 25 years for small defects (Qp:Qs <1.5:1) 1
• Regular monitoring for potential complications (aortic valve prolapse, infective endocarditis) 2

VSDs with Pulmonary Hypertension:

• Closure may be considered with left-to-right shunt (Qp:Qs ≥1.5:1) when PA pressure is 50% or more systemic 1
• Fenestrated devices or patches may be used to allow right heart decompression 1
• Consider PAH therapies before closure in borderline cases 1

Postoperative Care and Follow-up:

• Annual follow-up at ACHD center if residual issues exist (heart failure, shunts, PAH, AR) 2
• Follow-up every 3-5 years for small residual VSDs 2
• ECG monitoring for development of heart block 2

Potential Complications

• Residual VSD
• Complete heart block requiring pacemaker
• Ventricular dysfunction
• Pulmonary hypertensive crisis
• Aortic or tricuspid regurgitation
• Infective endocarditis 2

The approach to VSD closure must carefully balance the benefits of defect closure against the risks of intervention, with particular attention to preventing pulmonary vascular obstructive disease while avoiding unnecessary procedures for small defects that may not require intervention 3, 4.