What is the treatment for Ventricular Septal Defect (VSD)?

Treatment of Ventricular Septal Defect (VSD)

Surgical closure is recommended for adults with VSD who have evidence of 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

Assessment and Indications for Intervention

• VSDs are classified as perimembranous, supracristal, atrioventricular septal, and muscular types, with management strategies varying by type 2
• Hemodynamic assessment is crucial, with cardiac catheterization recommended when pulmonary hypertension is suspected 1
• Small restrictive VSDs without pulmonary hypertension, significant arrhythmias, or LV dysfunction typically require no intervention 1

Indications for VSD closure:

• Left ventricular volume overload with significant left-to-right shunt (Qp:Qs ≥1.5:1) 1
• Worsening aortic regurgitation caused by VSD (particularly perimembranous or supracristal types) 1
• History of infective endocarditis caused by VSD 1
• Failure to thrive despite optimal medical management 3

Medical Management

For patients with symptomatic VSDs not yet requiring or eligible for surgical intervention:

• Diuretic therapy with furosemide is recommended for infants with heart failure symptoms 3
• Consider adding spironolactone at higher furosemide doses to prevent potassium loss 3
• Regular monitoring of growth and development with serial echocardiographic evaluations 3

Surgical Approaches

Surgical Closure:

• Surgical repair is the gold standard for perimembranous VSDs due to the 1-5% risk of heart block associated with device closure 4
• Timing of surgery is critical to prevent pulmonary vascular obstructive disease 2
• Current surgical outcomes show excellent results with minimal mortality (0.5%) and very low complication rates 5

Percutaneous Device Closure:

• Appropriate for large muscular VSDs beyond infancy 4
• The Amplatzer Muscular VSD Occluder is FDA-approved for clinical use 2
• Not recommended for perimembranous VSDs due to higher risk of heart block 4

Hybrid Approach:

• Perventricular hybrid closure should be considered for apically or anteriorly located VSDs in infants 4
• May be used for large muscular VSDs in small babies 2

Contraindications to VSD Closure

• VSD closure should not be performed in adults with severe pulmonary arterial hypertension (PA systolic pressure >2/3 systemic) 1
• Avoid closure in patients with pulmonary vascular resistance greater than two-thirds systemic 1
• Contraindicated in patients with Eisenmenger physiology (net right-to-left shunt) 1

Follow-up Recommendations

• Lifelong regular follow-up is recommended for all patients with VSD, both operated and unoperated 1
• Particular attention should be paid to residual shunts, valve function, ventricular size and function, and pulmonary artery pressure 1
• Patients with repaired VSDs without significant residual abnormalities should be seen at least every 2-3 years 1
• Patients with residual abnormalities require more frequent follow-up 1

Outcomes and Prognosis

• Surgical closure of isolated VSD is highly effective with minimal risk of death, complete heart block, or reoperation 5
• Long-term survival after VSD repair in adults has improved over time 1
• Approximately 50% of large VSDs in infants may become small enough not to require surgical intervention if managed medically 3
• Small VSDs have excellent outcomes with no development of pulmonary vascular disease 6

Special Considerations

• For VSDs associated with other defects (e.g., coarctation of aorta), outcomes support consideration of a one-stage approach 7
• Careful monitoring for complications such as double-chambered right ventricle or subaortic stenosis is essential 3
• Avoid misdiagnosing heart failure as pneumonia in infants with VSD 3