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

Treatment of Ventricular Septal Defect (VSD)

Adults with VSD and hemodynamically significant left-to-right shunt (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 resistance. 1

Indications for VSD Closure

Class I Recommendations (Must Close)

• Hemodynamically significant shunt: VSD closure is mandatory when Qp:Qs ≥1.5:1 with evidence of left ventricular volume overload, provided PA systolic pressure <50% systemic and PVR <1/3 systemic 1

• Symptomatic patients: Those with heart failure symptoms attributable to left-to-right shunting require surgical or catheter-based closure if they don't have severe pulmonary vascular disease 2

• History of infective endocarditis: Patients with prior IE caused by VSD should undergo closure 2

Class IIa Recommendations (Reasonable to Close)

• Worsening aortic regurgitation: Surgical closure of perimembranous or supracristal VSD is reasonable when progressive AR develops from VSD-associated aortic valve prolapse 1, 2

• Asymptomatic with LV volume overload: Closure is reasonable even without symptoms if echocardiography demonstrates left ventricular enlargement 2

Class IIb Recommendations (May Consider)

• Post-IE history: Surgical closure may be reasonable in adults with history of IE caused by VSD if not otherwise contraindicated 1

• Elevated pulmonary pressures: Closure may be considered when Qp:Qs ≥1.5:1 even if PA systolic pressure is 50% or more of systemic and/or PVR is greater than one-third systemic 1

Class III (Harm) - Do NOT Close

VSD closure is contraindicated in adults with severe pulmonary arterial hypertension when PA systolic pressure exceeds two-thirds systemic, PVR exceeds two-thirds systemic, and/or a net right-to-left shunt exists (Eisenmenger syndrome). 1

Surgical Approach Selection

Surgical Closure Preferred For:

• Large perimembranous VSDs requiring patch closure with synthetic material (Dacron or Gore-Tex) 1, 3, 4

• Supracristal (subaortic) VSDs due to high risk of progressive aortic valve prolapse and regurgitation 1, 3, 4

• Inlet VSDs 3, 4

• VSDs with aortic valve prolapse requiring concomitant valve repair 1, 3, 4

Percutaneous Device Closure Considerations:

• Muscular VSDs: The Amplatzer Muscular VSD Occluder is FDA-approved and effective for large muscular defects 3, 4

• Perimembranous VSDs: Percutaneous closure with Amplatzer Membranous VSD Occluder is technically feasible but NOT recommended due to significant risk of complete heart block 3, 4

• Hybrid approach: May be used for large muscular VSDs in small infants 4

Medical Management

Medical therapy is not definitive treatment but serves as bridge to intervention or for inoperable cases:

• ACE inhibitors: For AV valve regurgitation and chronic heart failure symptoms 2, 5

• Diuretics (furosemide): For volume management and pulmonary congestion 2, 5

• Nitrates: If no hypotension, for symptom relief 5

Observation Without Intervention

Small restrictive VSDs (Qp:Qs <1.5:1) with normal pulmonary pressures can be managed conservatively with surveillance, as 25-year survival is 96% 1

Critical caveat: Even small supracristal or perimembranous defects require close monitoring, as 6% develop progressive aortic valve prolapse and AR 1

Timing of Intervention

• Infants with heart failure: Primary repair is superior to pulmonary artery banding, with mortality of 2.4% versus 19.3% for staged repair 6

• Adults: Early intervention prevents pulmonary vascular obstructive disease development 3, 4

• Post-MI VSD rupture: Immediate IABP insertion with early surgical repair (within 3-9 days) achieves 89% survival versus 92% first-year mortality without surgery 1, 7

Follow-Up Protocol

Annual Follow-Up Required For:

• Residual heart failure 1, 2
• Residual shunts 1, 2
• Pulmonary arterial hypertension 1, 2
• Aortic regurgitation 1, 2
• RV or LV outflow tract obstruction 1, 2

Every 3-5 Years For:

• Small residual VSD without other lesions 1

Surveillance Echocardiography Must Assess:

• Development of aortic or tricuspid regurgitation 2
• Degree of residual shunt 2
• Left ventricular function 2
• Pulmonary artery pressure 2
• Development of double-chambered right ventricle 2
• Development of discrete subaortic stenosis 2

Critical Pitfalls to Avoid

• Misdiagnosis: Small VSDs may be mistaken for innocent murmurs; holosystolic murmur with thrill at third-fourth intercostal space is characteristic 2

• Silent severe PAH: Patients with severe PAH may have no murmur, only single loud S2 with cyanosis/clubbing 2

• Delayed recognition of complications: Vigilant monitoring required for aortic valve prolapse, double-chambered RV, or subaortic stenosis development 2

• Inappropriate closure: Never close VSDs in Eisenmenger syndrome or when exercise-induced desaturation is present 1, 2

• Perimembranous device closure: Avoid percutaneous closure due to complete heart block risk 3, 4

Surgical Outcomes

Modern surgical VSD closure achieves:

• Operative mortality: 0.5% 8
• Complete heart block risk: 0% with current techniques 8
• Reoperation for residual VSD: 0% 8
• Long-term functional status: 99.5% asymptomatic at 2-year follow-up 8