From the Guidelines
The management of Ventricular Septal Defect (VSD) should prioritize a conservative approach for small restrictive defects, while larger defects may require surgical or transcatheter closure, depending on the presence of complications such as pulmonary hypertension or aortic regurgitation, as recommended by the 2019 AHA/ACC guideline 1.
Key Considerations
- Small restrictive defects of the muscular or membranous septum may be watched conservatively without need for operative intervention, with a 25-year survival rate of 96% for patients with small defects and low PA pressure 1.
- Larger defects may be repaired, but only in the absence of severe PAH and severely elevated pulmonary vascular resistance, which incurs a high perioperative risk 1.
- Trans-catheter device occlusion of muscular and perimembranous VSD is feasible, with trials demonstrating a good safety and efficacy profile 1.
Management Approach
- For patients with small VSDs, regular monitoring with echocardiograms is recommended to assess for any changes in defect size or development of complications such as aortic regurgitation or pulmonary hypertension.
- For patients with larger VSDs, surgical or transcatheter closure may be necessary to prevent complications such as heart failure, pulmonary hypertension, or endocarditis.
- The presence of aortic regurgitation or pulmonary hypertension may influence the decision to close the VSD, with earlier intervention recommended in these cases.
Complications and Risks
- Patients with unrepaired VSD are at increased risk of endocarditis, typically involving the tricuspid and pulmonic valves 1.
- Early attempts at surgical closure of nonrestrictive VSD in patients with Eisenmenger syndrome were associated with high mortality, and this approach is generally not recommended 1.
- The use of fenestrated devices and fenestrated surgical patches may be considered in patients with large VSD and PAH, to allow decompression of the right heart 1.
From the Research
Management of Ventricular Septal Defect (VSD)
The management of VSDs can be divided into several categories, including:
- Medical management: used for small VSDs with no significant symptoms, and includes endocarditis prophylaxis 2
- Surgical closure: recommended for large VSDs, VSDs with significant associated lesions, and VSDs with enlarged left ventricular size or deteriorating left ventricular function 2, 3, 4
- Device closure: can be used for muscular VSDs, and is still in the investigational stage for other types of VSDs 5, 2, 3, 4
- Hybrid approach: may be used for large muscular VSDs in small babies 3
- Transcatheter closure: can be used for postinfarct VSDs, and appears to be a durable option with low long-term mortality 6
Indications for Closure
The indications for closure of VSDs include:
- Moderate to large VSDs with enlarged left atrium and left ventricle or elevated pulmonary artery pressure (or both) and a pulmonary-to-systemic flow ratio greater than 2:1 3
- Large perimembranous VSDs, supracristal VSDs, and VSDs with aortic valve prolapse 3, 4
- VSDs with significant associated lesions such as aortic regurgitation, aortic valve prolapse, right or left ventricular outflow obstruction, tricuspid regurgitation, left ventricle to right atrial shunt, or recurrent endocarditis 2
Treatment Options
The treatment options for VSDs include:
- Surgical closure using techniques such as patch closure or direct closure 2, 3, 4
- Device closure using devices such as the Amplatzer Muscular VSD Occluder or the Amplatzer Membranous VSD Occluder 5, 3, 4
- Transcatheter closure using techniques such as the formation of an arteriovenous loop and deployment of a device in the defect 6
- Hybrid approach using a combination of surgical and transcatheter techniques 3