Ventricular septal defect treatment

and Leida Perez, M.D.

Associate Editor-In-Chief: Keri Shafer, M.D. [mailto:kshafer@bidmc.harvard.edu], Priyamvada Singh, MBBS

Small VSD
In infants with a small defect, reassurance of parents and close follow-up. Antibiotic use as prophylaxis for bacterial endocarditis.

Moderate and Large VSD
There is a greater risk of operative closure in early infancy than at age 1 to 2 years.

The diagnosis in an infant is usually made in the first few months and cardiac catheterization is performed:

a) if the defect is sufficiently large to allow equalization of pressures, (PAP/SP > .75) then an operation is urgently needed whenever cardiac failure occurs and is not responsive to medical management.

b) the risk of death from closing the defect in this circumstance is 10% to 20%, but this is less than the risk of leaving the defect unrepaired.

c) if CHF can be controlled medically, then careful observation in warranted with repeat cardiac catheterization at 12 to 15 months.

d) If the PAP/SP is > .75, then surgery is indicated, because a delay in closure may lead to progressive pulmonary vascular obstructive disease.

e) Further delay will not decrease the risk below that at 18 to 24 months (2% operative mortality).

f) The likelihood of closure of the defect after this age is remote.

g) If repeat cardiac catheterization at 12 to 15 months suggests that the defect is becoming smaller, (PAP/SP < .75), then further postponement of the operation is advisable. The likelihood of development of pulmonary obstructive disease is remote, the defect is also likely to continue to diminish in size.

h) Similarly, if at the original cardiac catheterization the PAP/SP was < .75, then postponement would be advisable.

i) Patients with PAP/SP < .75 should be followed until age 4 when they should undergo repeat cardiac catheterization.

j) At that time, even if the PAP/SP < .5, then operative closure of the VSD is advised if a large amount of pulmonary blood flow is present (Qp/Qs = 1.5 to 2.0). k) this is because the hemodynamic burden is significant and may handicap the growing child or cause irreversible LV changes and because the defect is of moderate size and is not showing evidence of spontaneous closure.

l) If Qp/Qs is 1.3 to 1.5, then further observation is warranted because of the hope that closure could still occur.

m) if Qp/Qs is < 1.3, then closure could be avoided altogether

Management of the Adolescent and Adult Patient
In general there are three presentations:

a) Small VSD with a PAP/SP that is normal, a Qp/Qs < 1.3. In this cases operation is unnecessary.

b) If Qp/Qs 1.3 to 1.5 the indications for surgery are borderline.

Moderate-sized VSD or moderate left-to-right shunt with PAP/SP < 0.5 and Qp/Qs 1.5 to 2.0, then operation is advised.

c) Large VSDs with PAP/SP > 0.75 but with small Qp/Qs due to significant pulmonary vascular obstructive disease. Deemed inoperable when the resistance Rp, is greater than 10 unitsx m2. The pulmonary hypertension may persist postoperatively.

Lung biopsy does not add information that is helpful in making this decision.

The management of the patient with acquired infundibular stenosis is the same as for the patient with tetralogy of Fallot.