Percutaneous VSD Device Closure in Children
Primary Recommendation
Percutaneous device closure is reasonable for hemodynamically significant muscular VSDs in children >5 kg with adequate septal rims, but perimembranous VSDs should undergo surgical closure due to an unacceptably high risk of complete heart block with device closure. 1, 2
Indications for Closure
Hemodynamic significance is the cornerstone indication:
- Left ventricular volume overload with evidence of LV or left atrial enlargement warrants closure in infants >5 kg, children, and adolescents 1, 3
- Qp:Qs ratio ≥1.5:1 with pulmonary artery pressure <50% systemic and pulmonary vascular resistance <1/3 systemic resistance 4
- Symptomatic patients with dyspnea, failure to thrive, or heart failure attributable to left-to-right shunting 3, 5
- History of infective endocarditis regardless of hemodynamic significance 3
- VSD-associated aortic valve prolapse causing progressive aortic regurgitation 3
Critical Pre-Procedure Evaluation
Anatomic Assessment via Echocardiography
Transthoracic echocardiography is the primary diagnostic tool and must characterize: 1, 3
- VSD type and location (perimembranous, muscular, inlet, or supracristal)
- Defect size and number (single vs. multiple "Swiss cheese" defects)
- Adequacy of septal rims surrounding the defect to ensure device stability without interference with atrioventricular valves or great vessels 1
- Degree of LV volume overload and ventricular function 3
- Presence of aortic valve prolapse or regurgitation 3, 4
- Estimated pulmonary artery pressure 1, 3
Hemodynamic Assessment
If pulmonary hypertension is suspected on echo, cardiac catheterization is mandatory to measure: 4
- Pulmonary vascular resistance (must be <2/3 systemic)
- Pulmonary artery systolic pressure (must be <2/3 systemic)
- Confirmation of net left-to-right shunt (Qp:Qs >1.5) 4
Closure is contraindicated if: 4
- Pulmonary vascular resistance >2/3 systemic
- Net right-to-left shunt present
- Eisenmenger physiology with exercise-induced desaturation 3
Device Selection and Technique
VSD Type Determines Approach
Muscular VSDs:
- Amplatzer Muscular VSD Occluder is the device of choice for muscular defects remote from the tricuspid valve and aorta 4, 6, 7
- Percutaneous or hybrid approaches are effective for large muscular VSDs 7
- Success rates approach 97-100% with immediate complete closure in 71% of cases 5
Perimembranous VSDs:
- Surgical closure is strongly preferred over device closure 4, 7
- The Amplatzer Membranous VSD Occluder carries a 22% risk of complete heart block, occurring from 17 days to 37.5 months post-implantation 2
- This heart block risk is unacceptably high and makes device closure inadvisable for perimembranous defects 7, 2
- Off-label use of duct occluder devices (Amplatzer Duct Occluder I or Lifetech) shows promise with only 1.4% complete heart block rate in a multicenter series, but this remains investigational 8
Other VSD Types:
- Supracristal (subarterial) and inlet VSDs require surgical closure 7
- VSDs involving prolapsed aortic valve leaflets mandate surgical repair 7
Technical Considerations
- Median defect size for device closure is 6 mm (range typically ≤12 mm) 5, 8
- Vascular access is typically via femoral vein in 76% of cases 8
- Device sizing must account for adequate rim tissue without impinging on valves or conduction system 1
Risks and Complications
Device-specific complications include: 1
- Device migration/embolization
- Tricuspid and mitral valve regurgitation (acute mitral regurgitation from leaflet entrapment reported) 5
- Complete heart block (especially with perimembranous defects—22% with Amplatzer Membranous VSD Occluder) 2
- Hemolysis
- Transient ischemic attack/stroke
- Ventricular tachycardia (usually nonsustained and self-resolving) 5
Early complication rate is approximately 7.8% in contemporary series 8
Post-Procedure Management
Immediate Follow-Up
- Residual shunt assessment: Trivial residual shunt occurs in 21-29% immediately post-procedure, with most resolving by 6 months 5, 8
- Complete closure rate: 71% immediate, improving to 86% at latest follow-up 5
Long-Term Surveillance
Regular echocardiographic monitoring is essential to assess: 3
- Development of aortic or tricuspid regurgitation
- Degree of residual shunt
- Left ventricular function
- Pulmonary artery pressure
- Development of double-chambered right ventricle
- Development of discrete subaortic stenosis
Follow-up intervals: 4
- Patients with LV dysfunction, residual shunt, pulmonary hypertension, aortic regurgitation, or outflow tract obstruction should be seen annually at specialized congenital heart disease centers
- If repaired before age 25 with complete closure and no residual abnormalities, long-term prognosis is excellent 4
Critical Pitfalls to Avoid
- Do not attempt device closure of perimembranous VSDs with the Amplatzer Membranous VSD Occluder due to prohibitive heart block risk 7, 2
- Do not close small VSDs (<5 mm) without hemodynamic significance 3
- Do not proceed with closure if pulmonary vascular resistance is elevated (>2/3 systemic) or Eisenmenger physiology is present 3, 4
- Ensure all VSD closures are performed by operators with training and expertise in congenital heart disease 4
- Vigilant monitoring for late-onset complete heart block is required, as it can occur up to 37.5 months post-device implantation 2