What is the relationship between aortic regurgitation (AR) and ventricular septal defect (VSD)?

From the Guidelines

Aortic regurgitation (AR) is associated with ventricular septal defect (VSD), particularly in cases where the VSD is large or perimembranous, and can lead to progressive AR.

Relationship between AR and VSD

• The presence of a VSD, especially a supracristal or perimembranous defect, can cause aortic valve prolapse and resultant AR, which may be progressive 1.
• In patients with unrepaired VSD, there is an increased risk of complications, including AR, infective endocarditis, and pulmonary arterial hypertension.
• The management of VSD in adults depends on the size and location of the defect, as well as the presence of symptoms and complications such as AR.

Management of VSD with AR

• Patients with VSD-associated prolapse of an aortic valve cusp causing progressive AR should be considered for surgery 1.
• Ideally, the VSD is closed if AR is progressive to avoid the continued worsening of AR and the need for aortic valve replacement 1.
• Aortic valve repair may be performed at the time of VSD closure in an effort to stabilize or improve AR 1.

Key Considerations

• The presence of severe pulmonary arterial hypertension and elevated pulmonary vascular resistance are contraindications to VSD closure 1.
• Patients with Eisenmenger syndrome and no left-to-right shunting should not undergo VSD closure due to high mortality risk 1.

From the Research

Relationship between Aortic Regurgitation and Ventricular Septal Defect

The relationship between aortic regurgitation (AR) and ventricular septal defect (VSD) is complex and has been studied extensively. Some key points to consider include:

• The development of AR is a rare but serious complication of subaortic VSDs, with a frequency of 4.5% of all isolated VSDs encountered over a 5-year period 2.
• The location of the VSD is an important factor, with infundibular septum defects being the most common (59%) 2.
• Hemodynamic defects are often small, except in cases where the Q(p)/Q(s) ratio is greater than 2 2.
• Surgical closure of VSDs can improve AR, with 15 out of 16 patients showing improvement or resolution of AR after surgery 2.

Predictors of Aortic Regurgitation Progression

Several studies have identified predictors of AR progression after VSD repair, including:

• Severity of preoperative AR and older age (>15 years) at VSD repair 3.
• Presence of aortic valvular or subvalvular anomalies, such as aortic valve prolapse or ruptured sinus Valsalva aneurysm 3.
• Type of VSD, with supracristal VSDs being more commonly associated with AR 4.
• Female gender, which may be associated with a higher likelihood of improvement in AR after surgery 5.

Clinical Course and Outcomes

The clinical course and outcomes of patients with VSD and AR can be unpredictable, with some patients experiencing improvement or resolution of AR after surgery, while others may experience progression or development of new AR 3, 4, 5, 6.

• Early surgical closure of VSDs is advisable to prevent progression of AR and improve outcomes 2, 5.
• Close clinical control and regular echocardiographic monitoring are essential for patients with VSD and AR 6.
• The incidence of new cases of AR arising during long-term follow-up can be significant, emphasizing the need for ongoing surveillance 6.