Treatment of Ventricular Septal Defect (VSD)
Adults with VSD and hemodynamically significant left-to-right shunts (Qp:Qs ≥1.5:1) with left ventricular volume overload should undergo VSD closure when pulmonary artery systolic pressure is less than 50% of systemic pressure and pulmonary vascular resistance is less than one-third systemic. 1
Indications for Surgical Closure in Adults
Class I Recommendations (Must Close)
Hemodynamically significant shunts require closure when all of the following criteria are met: 1
- Evidence of left ventricular volume overload
- Qp:Qs ratio ≥1.5:1
- PA systolic pressure <50% of systemic pressure
- Pulmonary vascular resistance <1/3 systemic resistance
Class IIa Recommendations (Reasonable to Close)
Surgical closure is reasonable for perimembranous or supracristal VSDs when there is worsening aortic regurgitation caused by the VSD, even without meeting the hemodynamic criteria above. 1
Class IIb Recommendations (May Consider Closure)
Closure may be considered in the following scenarios: 1
- History of infective endocarditis caused by VSD (if not otherwise contraindicated)
- Net left-to-right shunt (Qp:Qs ≥1.5:1) when PA systolic pressure is ≥50% systemic and/or pulmonary vascular resistance is >1/3 systemic
Class III Recommendations (Do Not Close - Harm)
VSD closure is contraindicated in adults with severe pulmonary arterial hypertension when: 1
- PA systolic pressure >2/3 systemic pressure
- Pulmonary vascular resistance >2/3 systemic resistance
- Net right-to-left shunt is present (Eisenmenger syndrome)
This represents a critical pitfall: attempting closure in Eisenmenger physiology carries prohibitive mortality risk and worsens outcomes. 1
Management of Infants and Children
Medical Management
Diuretic therapy is the first-line treatment for symptomatic infants with VSD presenting with heart failure symptoms (including cough, failure to thrive): 2
- Furosemide at doses <2 mg/kg/day orally
- Add spironolactone at higher furosemide doses to prevent potassium loss
- Low sodium formulas may be considered
Important caveat: Cough in VSD infants may represent heart failure rather than pneumonia—a common misdiagnosis that delays appropriate treatment. 2
Surgical Indications in Infants/Children
Surgery should be performed when: 2, 3
- Significant symptoms persist despite optimal medical therapy
- Large left-to-right shunt with LV volume overload
- Failure to gain weight despite medical management
- Large VSD with significantly elevated pulmonary artery pressure after 6 months of age
- History of infective endocarditis
Timing consideration: Approximately 50% of large VSDs may become small enough not to require surgery if medical management is successful, making early aggressive medical therapy worthwhile. 2, 4
Surgical Approach by VSD Type
Surgical closure is recommended for: 3, 5
- Large perimembranous VSDs
- Supracristal VSDs
- Inlet VSDs
- VSDs with aortic valve prolapse
Percutaneous closure with Amplatzer Muscular VSD Occluder is appropriate for large muscular VSDs, as this is the only FDA-approved device for VSD closure. 3
Avoid percutaneous closure of perimembranous VSDs with Amplatzer Membranous VSD Occluder due to significant risk of complete heart block. 5
Natural History and Conservative Management
Small restrictive VSDs (Qp:Qs <1.5:1) can be managed conservatively with observation, as they have excellent prognosis without intervention. 1, 4
Moderate VSDs show favorable natural history: 75% do not require surgery, and 58% normalize pulmonary artery pressures on follow-up. 4
Large-restrictive VSDs have better outcomes than nonrestrictive defects: only 12% require surgery in infancy compared to 51% with nonrestrictive defects, and 62% close enough to never require surgery. 4
Critical Pitfalls to Avoid
Do not delay intervention in large VSDs with significant shunts, as pulmonary vascular obstructive disease develops and becomes irreversible, making the patient inoperable. 3, 5
Do not perform unnecessary procedures on small defects—the surgical mortality, though low at 0.5%, still exists and is not justified for hemodynamically insignificant lesions. 6
Monitor for aortic valve prolapse in perimembranous and supracristal VSDs, as progressive aortic regurgitation changes the indication for surgery even without significant shunting. 1, 2
Expected Surgical Outcomes
Modern surgical closure achieves excellent results: 6
- Operative mortality: 0.5%
- Complete heart block: 0%
- Reoperation for residual VSD: 0%
- 99.5% of patients asymptomatic at follow-up