VSD Closure Recommendation for High Flow, Low Resistance with Moderate Pulmonary Hypertension
Based on your hemodynamic parameters (Qp:Qs 12:1, PVR 0.2 Wood units), VSD closure is strongly indicated and should be performed, as you meet all criteria for Class I recommendation with pulmonary vascular resistance well below one-third systemic resistance. 1
Definitive Indication for Closure
Your case represents an ideal candidate for VSD closure based on the following hemodynamic profile:
- Qp:Qs ratio of 12:1 far exceeds the threshold of ≥1.5:1 required for closure 1, 2
- PVR of 0.2 Wood units is dramatically below the critical threshold of <one-third systemic resistance (typically <4-5 Wood units) 1
- The "high flow, low resistance" pattern indicates significant left-to-right shunting with preserved pulmonary vascular bed reactivity 1
- Your moderate pulmonary hypertension is flow-mediated rather than resistance-mediated, which is reversible after closure 1, 2
Understanding Your "Moderate Pulmonary Hypertension"
The moderate pulmonary hypertension in your case is hemodynamically favorable for closure:
- When PVR is <one-third systemic (as yours is at 0.2), elevated PA pressure reflects increased flow rather than irreversible vascular disease 1
- The ACC/AHA guidelines specifically permit closure when PA systolic pressure is <50% of systemic pressure with your low PVR 1, 2
- This distinguishes you from patients with Eisenmenger physiology who have PVR >two-thirds systemic and are contraindicated for closure 1
Surgical Approach Recommendation
Surgical closure is the preferred method for your VSD:
- All VSD closures should be performed by surgeons with congenital heart disease expertise 1, 3
- Device closure may be considered only for muscular VSDs in specific anatomic locations remote from the tricuspid valve and aorta 3
- The surgical approach typically involves patch closure through a right atrial approach 1
Critical Pre-Operative Considerations
Before proceeding to closure, ensure evaluation for:
- Aortic valve prolapse and regurgitation, particularly if you have a perimembranous or supracristal VSD, as 6% develop progressive AR 1, 2
- Associated muscular VSDs that may only manifest after closure of the dominant defect 1
- Left ventricular function and volume overload, which should be present given your massive shunt 1, 2
- Double-chambered right ventricle or subaortic stenosis, which can develop and alter management 1, 2
Post-Operative Management Expectations
Following closure with your hemodynamic profile:
- Expect significant reduction in PA pressures as the flow-mediated component resolves 1, 4
- Annual follow-up at an Adult Congenital Heart Disease center is required if residual issues develop 1, 2
- Every 3-5 years if complete closure with no residual shunt or complications 1
- Surveillance echocardiography should assess for residual shunt, aortic regurgitation, ventricular function, and PA pressure 2
Why You Are NOT in the "Gray Zone"
Your case does not fall into the controversial IIb recommendation category (PA pressure ≥50% systemic and/or PVR >one-third systemic) where closure "may be considered" 1. Your extremely low PVR of 0.2 places you firmly in the Class I indication category where closure "should" be performed 1, 2.
Absolute Contraindications That Do NOT Apply to You
VSD closure would be contraindicated (Class III: Harm) only if you had 1, 3:
- PA systolic pressure >two-thirds systemic
- PVR >two-thirds systemic
- Net right-to-left shunt (Eisenmenger syndrome)
None of these apply to your case.