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Natural aortic valve complications of ventricular septal defect: a prospective cohort study
Thanarat Layangool1, Tawatchai Kirawittaya, Chaisit Sangtawesin
1Cardiology Unit, Queen Sirikit National Institute of Child Health, Department of Medical Services, College of Medicine, Rangsit University, Bangkok, Thailand. t_layangool@yahoo.com
Insights
Subpulmonic ventricular septal defects (VSD) show a high incidence of aortic valve prolapse (AVP) and aortic regurgitation (AR), significantly more than perimembranous VSD. These complications in infancy warrant early cardiac surgery.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
- Echocardiography
Background:
- Ventricular septal defect (VSD) is a common congenital heart anomaly.
- Aortic valve prolapse (AVP) and aortic regurgitation (AR) are potential complications, particularly in certain VSD types.
- Understanding the incidence and onset of AVP and AR in VSD is crucial for management.
Purpose of the Study:
- To investigate the incidence and timing of aortic valve prolapse (AVP) and aortic regurgitation (AR) in children with ventricular septal defect (VSD).
- To compare the occurrence of AVP and AR between different types of VSD, specifically subpulmonic and perimembranous.
- To identify risk factors and implications for surgical intervention.
Main Methods:
- A prospective cohort study involving infants diagnosed with isolated VSD.
- Regular clinical follow-up and echocardiographic assessments over a 6-year period.
- Evaluation of VSD size, location, flow, aortic valve morphology, and presence of AR.
Main Results:
- Subpulmonic VSD had a significantly higher incidence of AVP (87.1%) and AR (37.1%) compared to perimembranous VSD (16.4% and 5.3%, respectively).
- Relative risks for AVP and AR were substantially elevated in subpulmonic VSD (5.30 and 6.95, respectively).
- Survival analysis showed earlier and more frequent development of AVP and AR in subpulmonic VSD patients from infancy.
Conclusions:
- Subpulmonic VSD is associated with a markedly higher incidence of AVP and AR compared to perimembranous VSD.
- These complications arise early in infancy and are significant indicators for timely cardiac surgery.
- Early detection and management are essential for improving outcomes in VSD patients.
Objective:
To study the incidence and onset of aortic valve prolapse (AVP) and aortic regurgitation (AR) in the ventricular septal defect (VSD).
Study Design:
A prospective cohort study
Population:
The less than one-year-old children with diagnosis of isolated VSD were studied from October 2000 to September 2006 at Queen Sirikit National Institute of Child Health. Clinical follow-up and echocardiographic studies were scheduled every 2-3 months in the first year of age and then every 6 months to evaluate the size, location, flow across VSD, aortic valve morphology and aortic regurgitation.
Results:
Three hundred and twenty-one cases of VSD were followed up. One was excluded due to associated hypoplastic RV An overall of 2,644 echocardiograms were performed. The percentage of perimembranous, subpulmonic, muscular inlet and multiple types were 70.3%, 19.4%, 5.6%, 3.1% and 1.6%, respectively. Size of the VSD was diagnosed to be small, moderate, and large VSD in 62.5%, 15.9% and 21.6% respectively. At the end of the study, the incidence of AVP in subpulmonic VSD was 87.1% compared to 16.4% in perimembranous VSD, with a relative risk of 5.30 and the incidence of AR in subpulmonic VSD was 37.1% compared to 5.3% in perimembranous VSD, with a relative risk of 6.95. From the survival analysis, the patient with subpulmonic VSD developed AVP at 46%, 77%, 90% and 94% compare to 8%, 13%, 20% and 23% of perimembranous VSD at 12, 24, 36 and 48 months of age respectively (p < 0.001). The patient with subpulmonic VSD developed AR at 8%, 17%, 35% and 38% compare to 2%, 4%, 5% and 7% of perimembranous VSD at 12, 24, 36 and 48 months of age respectively (p < 0.001). At the end of the study, ninety-six cases (30%) underwent cardiac operation with the indication of heart failure or the occurrence of AR. Sixty one cases (19.1%), including two cases of subpulmonic type had spontaneous closure of VSD. Seven cases (2.2%) had lost to follow up and five cases (1.6%) died during the follow up period.
Conclusion:
The incidence of AVP and AR are high in subpulmonic VSD being much higher than perimembranous VSD with a relative risk of 5.30 and 6.95 respectively. These complications are significantly from infancy period and are an indication for early cardiac surgery.
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