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Published on: February 8, 2022
Long-term outcome of patients with ventricular septal defect considered not to require surgical closure during
Harald M Gabriel1, Maria Heger, Petra Innerhofer
1Department of Cardiology, University of Vienna, Vienna, Austria.
Insights
Long-term outcomes for small ventricular septal defects (VSDs) managed non-surgically in childhood are favorable. Most patients remain asymptomatic with normal heart function, indicating successful conservative management of VSD.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Adult Congenital Heart Disease
Background:
- Small ventricular septal defects (VSDs) historically managed conservatively may present long-term complications in adulthood.
- Recent data suggest a need to re-evaluate the long-term outcomes of non-surgically treated small VSDs.
Purpose of the Study:
- To assess the long-term outcomes of patients with small ventricular septal defects (VSDs) initially deemed not to require surgical closure in childhood.
- To evaluate the development of serious complications in adulthood for this patient cohort.
Main Methods:
- A cohort of 229 patients with small VSDs (normal pulmonary artery pressure, <50% shunt, normal pulmonary vascular resistance, no VSD-related aortic regurgitation or symptoms) were followed in an adult congenital heart disease program.
- Regular physical examinations, electrocardiography, echocardiography, and intermittent exercise tests and Holter monitoring were utilized.
- Follow-up data were collected over extended periods to assess long-term clinical status and cardiac function.
Main Results:
- Spontaneous VSD closure occurred in 6% of patients; 97% completed follow-up.
- Excellent event-free survival (99.1% at 3 years, 95.5% at 8 years) with minimal instances of endocarditis or need for surgery.
- The vast majority of patients remained asymptomatic (94.6%) with normal left ventricular size, systolic function, and pulmonary artery pressure at long-term follow-up.
Conclusions:
- Well-selected patients with small VSDs demonstrate good long-term outcomes without surgical intervention in childhood.
- Conservative management is appropriate for small VSDs provided specific criteria (shunt fraction, left ventricular volume overload, pulmonary artery pressure, aortic regurgitation, symptoms) are met.
- This approach minimizes the need for surgical closure during childhood while maintaining favorable cardiac health into adulthood.
Objectives:
The purpose of the study was to assess the long-term outcome of patients with small ventricular septal defects (VSDs) considered not to require surgical closure during childhood.
Background:
Although patients with small VSDs have generally been considered not to require surgery, more recent data suggest that a significant percentage of these patients develop serious problems during adult life.
Methods:
A total of 229 consecutive patients (115 females) with a VSD considered too small to require surgery during childhood as defined by normal pulmonary artery pressure, less than 50% shunt, pulmonary vascular resistance < or =200 dynes x s cm(-5), no VSD-related aortic regurgitation (AR), and no symptoms and who had no additional hemodynamically relevant heart defect were followed in an adult congenital heart disease program. Physical examination, electrocardiography, and echocardiography were performed in all patients in one- to three-year intervals; exercise tests and Holter monitoring were performed in 140 and 127 patients, respectively.
Results:
Follow-up was completed in 222 patients (97%). Mean age at last visit was 30 +/- 10 years. Spontaneous VSD closure was observed in 14 patients (6%). No patients died, four patients (1.8%) had an episode of endocarditis, of whom two required aortic valve replacement, and one additional patient (0.4%) had surgical closure for hemodynamic reasons. For 118 patients who entered the study between 1993 and 1996 and were prospectively followed for 7.4 +/- 1.2 years, event-free survival with end points defined as death, endocarditis or heart surgery was 99.1 +/- 0.8% at three years, 96.5 +/- 1.7% at six years and 95.5 +/- 1.9% at eight years. At last visit, 94.6% of all patients studied were symptom free. Left ventricular (LV) size by echocardiography was normal in 198 (89%) patients, borderline in 23 patients and definitely enlarged in only one patient. None had systolic LV dysfunction, and pulmonary artery pressure (PAP) was normal in all patients. Mean exercise capacity was 92 +/- 21% of expected, and 87% of patients had no arrhythmias on Holter monitoring, with the remainder showing benign rhythm disorders.
Conclusions:
Outcome in well-selected patients with a small VSD is good. Surgical closure does not appear to be required during childhood as long as left-to-right shunt is <50% and signs of LV volume overload are absent, when PAP is not elevated, and no VSD-related AR or symptoms are present.
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