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Operative closure of isolated defects of the ventricular septum: planned delay
Insights
Timing VSD closure is key. Early surgery is often needed for infants with heart failure, but delaying operations for selected patients can reduce surgical risks.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Ventricular septal defect (VSD) closure timing is challenging due to balancing surgical risks with hemodynamic status, infant age, and size.
- Individualized approaches to VSD management have evolved over the past six years.
Purpose of the Study:
- To evaluate the individualized approach to the timing and necessity of operative closure for isolated VSD.
- To determine optimal criteria for surgical intervention in infants and children with VSD.
Main Methods:
- Retrospective analysis of 133 patients with VSD evaluated over six years.
- Categorization of patients based on age, clinical presentation (congestive failure, growth retardation), shunt size, and pulmonary vascular resistance.
Main Results:
- 71 out of 133 patients underwent VSD closure.
- 40 younger patients (≤2 years) required surgery due to failure or growth issues; 45 were managed non-operatively.
- 31 older patients had large shunts requiring surgery; 17 remained well without operation. Infants weighing ≥4 kg survived surgery, while 3 smaller infants died.
Conclusions:
- Most infants with VSD and large shunts benefit from early closure.
- Delayed surgical intervention, guided by hemodynamic and clinical criteria, can minimize risks, especially in neonates with severe failure.
- Careful patient selection and timing are crucial for optimizing outcomes in VSD management.
Abstract:
Selection of patients and the timing of operation for closure of ventricular septal defect (VSD) can be difficult because the risk of operation must be balanced against the hemodynamic abnormality and the age and size of the infant. In the past 6 years we have individualized our approach to the timing and necessity of operation in the patient with an isolated VSD. During this period, 133 patients with VSD were evaluated, and 71 underwent operative closure of the VSD. Of the 133 patients, 90 were 2 years old or younger, and 40 of them required operation because of congestive failure and growth retardation. Of the 45 infants who did not undergo operation, 17 have small intracardiac shunts with normal pulmonary vascular resistance while the other 28 infants remain compensated and are growing despite moderate left-to-right shunts. A persistent, large intracardiac shunt was the indication for operation in 31 of the 48 older patients; the other 17 older patients remain well. Although 3 severely growth-retarded infants (2 to 4 kg) died soon after operation, all infants weighing 4 kg or more survive. No child has died during preoperative observation, and irreversible pulmonary vascular changes have not occurred. Most infants with VSD and large intracardiac shunts do require early VSD closure, but the risk of operation remains high in the tiny neonate with profound failure. With appropriate hemodynamic and clinical criteria, operation for selected infants can be delayed so that the risk of operation can be minimized.