Is a 5-year-old male with a significant 6-8 mm Ventricular Septal Defect (VSD) and left to right shunt indicated for VSD device closure without a device or delivery system?

VSD Device Closure in a 5-Year-Old with 6-8mm Defect

This 5-year-old male with a significant 6-8mm VSD and left-to-right shunt is indicated for VSD closure, but device closure is NOT the appropriate method—surgical closure should be performed instead. 1

Primary Indication for Closure

The child meets clear criteria for VSD closure based on the defect size and hemodynamic significance:

• Closure is definitively indicated when there is evidence of left ventricular volume overload with Qp:Qs ≥1.5:1, provided pulmonary artery systolic pressure is <50% of systemic pressure and pulmonary vascular resistance is <1/3 systemic resistance 1
• A 6-8mm VSD with left-to-right shunt in a 5-year-old almost certainly produces significant hemodynamic consequences including LV volume overload 2
• Without closure, this child faces progressive risks including heart failure, pulmonary hypertension, endocarditis (2 per 1000 patient-years), and potential development of irreversible pulmonary vascular disease 2

Why Surgical Closure, Not Device Closure

All VSD closures should be performed by surgeons with training and expertise in congenital heart disease 1, and here's why device closure is inappropriate for this patient:

• Device closure of VSDs is only considered for muscular VSDs that are remote from the tricuspid valve and aorta 1
• The question does not specify the VSD type, but the most common VSDs requiring closure at this age are perimembranous defects (accounting for 70-80% of VSDs) 2
• Perimembranous VSDs carry risks of aortic valve prolapse and aortic regurgitation, making surgical approach safer 2
• Device closure of perimembranous VSDs carries significant risks of complete heart block due to proximity to the conduction system 2

Critical Pre-Closure Assessment Required

Before proceeding with any closure, you must exclude contraindications:

• Do NOT close if pulmonary artery systolic pressure is >2/3 systemic, pulmonary vascular resistance is >2/3 systemic, or there is net right-to-left shunt 1
• Echocardiography must confirm the VSD location, assess for LV volume overload, estimate pulmonary artery pressure, and exclude aortic valve prolapse (especially important for perimembranous and supracristal defects) 2
• If pulmonary hypertension is suspected on echo, cardiac catheterization is mandatory to measure pulmonary vascular resistance before proceeding 2

Special Considerations for This Age Group

At 5 years old, this child is in an optimal window for intervention:

• Spontaneous closure is unlikely for a 6-8mm defect at this age—most spontaneous closures occur in the first 2 years of life 2
• Early surgical repair (before age 25 years) provides the best long-term outcomes with minimal risk of late arrhythmias 2
• Without surgery, approximately 50% of patients with large nonrestrictive VSDs develop Eisenmenger syndrome, though this typically takes years to develop 2

Surgical Approach and Timing

Surgical closure should be performed through a right atrial approach by a congenital heart surgeon 3:

• The procedure involves cardiopulmonary bypass with patch closure of the defect
• If pulmonary vascular resistance is elevated (but still <2/3 systemic), some surgeons leave a small atrial communication as a "pop-off" to reduce perioperative mortality, though this is controversial 3
• Surgery should not be delayed once the indication is established, as progressive LV volume overload and pulmonary vascular changes can occur 2

Device Closure Scenarios (Not Applicable Here)

Device closure would only be considered if:

• The VSD is muscular (mid-septal or apical), not perimembranous 1
• The defect is remote from both the tricuspid valve and aortic valve 1
• There is severe LV chamber enlargement or pulmonary hypertension making surgery higher risk 1
• Even then, hybrid perventricular approaches may be preferred over transcatheter approaches in young children 2

Post-Closure Follow-Up

After surgical closure, this child will require:

• Follow-up every 1-2 years at a congenital heart disease center 1
• Echocardiographic surveillance for residual shunt, ventricular function, and development of complications 2
• If repaired before age 25 with complete closure and no residual abnormalities, long-term prognosis is excellent with minimal need for ongoing specialized care 2