Spontaneous closure of muscular trabecular ventricular septal defect: comparison of defect positions

The Natural and Unnatural History of Ventricular Septal Defects Presenting in Infancy: An Echocardiography-Based Review

BACKGROUND

Ventricular septal defect (VSD), the most common congenital heart defect, accounts for 40% of heart malformations. Despite this prevalence, there remains no consensus on the utility of echocardiography to guide modern-era treatment. In this study, we evaluated patients with isolated VSDs to test the hypothesis that echocardiographic evidence of left ventricular (LV) volume overload and type of VSD are associated with surgical intervention and to identify useful echocardiographic indicators for management of VSDs in infants and children.

METHODS

We reviewed 350 patients with VSDs diagnosed during the first year of life. Echocardiographic measurements were made at the time of diagnosis and at the endpoint. The VSD area was calculated using inner edge to inner edge dimensions obtained from two planes and indexed to body surface area. Aortic annulus dimension, left atrium to aortic root ratio, LV end-diastolic diameter, left atrial volume, VSD velocity-time integral, ejection fraction, and pulmonary to systemic blood flow ratio (Qp:Qs) were measured using conventional methods.

RESULTS

One hundred seventy-seven muscular (50.5%) and 162 perimembranous (46%) VSDs accounted for the vast majority of defects. Only seven (4%) muscular defects required surgical closure, while 76 (47%) perimembranous defects required surgery. Indexed VSD area, VSD to aortic valve ratio, indexed left atrium volume, LV end-diastolic diameter, VSD velocity-time integral, and Qp:Qs at diagnosis were significantly different between the surgical and nonsurgical groups. Ventricular septal defect area > 50 mm²/m² at initial diagnosis was independently associated with risk for surgery (P = .0055).

CONCLUSIONS

Indexed VSD area is an echocardiographic variable that can be easily measured at diagnosis and can provide insight into the likelihood of requiring surgical intervention regardless of the type and location of the defect.

A review of isolated muscular ventricular septal defect

BACKGROUND

Color Doppler echocardiography greatly facilitates the diagnosis of isolated muscular ventricular septal defect with a small shunt.

DATA SOURCES

Original research articles were collected from database, including PubMed and Google scholar. Relevant articles about muscular ventricular septal defect were included.

RESULTS

The frequency of isolated muscular ventricular septal defect is 5.7% in preterm infants and 1.1-5.3% in term infants. Spontaneous closure in muscular ventricular septal defect occurs with higher frequency and earlier than in perimembranous ventricular septal defect. Approximately 80-90% of isolated muscular ventricular septal defect closes spontaneously by 12 months of age. Midventricular muscular ventricular septal defect is spontaneously closed earlier in the short term, but no site difference is found in the long term. The spontaneous closure mechanism is regarded as aposition of the muscle tissue or fibrous tissue formation in the right ventricular side, but in rare cases involves aneurysm formation of the fibrous tissue. Regarding spontaneous closure of isolated muscular ventricular septal defect diagnosed for the fetus, further studies are needed. Chromosomal microarray analysis of fetuses with isolated muscular ventricular septal defect has revealed that it is not a severe risk factor of chromosomal abnormalities.

CONCLUSIONS

This paper presents a review of the history of the diagnosis and frequency of ventricular septal defect, with discussion of its natural history from the fetal period to after birth in patients with isolated muscular ventricular septal defect.

Spontaneous Closure Rates of Ventricular Septal Defects (6,750 Consecutive Neonates)

Although ventricular septal defect (VSD) is a common and simple congenital heart disease in newborns, its true incidence and spontaneous closure (SC) rate remains topics of controversy. This study aims to provide data on the true incidence and SC rate of VSD in the Chinese neonatal population. We conducted a prospective study at 3 hospitals, all newborns underwent echocardiography. Those with a diagnosis of isolated VSD were included in the study group and underwent a 7-year follow-up period. In 6,750 newborns, VSDs were detected in 113 cases (incidence rate of 16.7%), accounting for 62.8% of congenital heart disease, of which 35 were perimembranous (5.2%), 72 were muscular (10.7%), and 6 were doubly committed juxta-arterial (0.9‰). During the 7-year follow-up period, 18 cases required surgical or transcatheter closure. The SC rate in those with perimembranous VSD and muscular VSD (mVSD) were 51.4% (18 of 35) and 97.2% (70 of 72), respectively. Excluding doubly committed juxta-arterial, perimembranous site and defects ≥4 mm are risk factors for VSD that do not spontaneously close. Independent predictive factors for perimembranous VSD which do not spontaneously close is defects ≥4 mm. There was no significant difference in the SC rate at different times between the 4 mVSD sites. In conclusion, this study provides the true incidence and SC rate for Chinese newborns with VSD.

Prediction of spontaneous closure of ventricular septal defect and guidance for clinical follow-up

AIM

To predict the spontaneous closure of ventricular septal defect (VSD) and assist pediatrician to manage VSD children.

METHODS

Between January 2008 and December 2016, 132 children diagnosed with isolated VSD by echocardiography were enrolled. All participating children were followed-up by echocardiography yearly until the closure of VSD or 6 years old. The clinical indicators and echocardiographic parameters of patients were collected. Statistically significant factors were used to establish a Logistic Regression model for predicting spontaneous closure of VSD. Receiver operating characteristic (ROC) analysis was used to assess the specificity and sensitivity of Logistic Regression model.

RESULTS

Spontaneous closure occurred in 60% of all patients; 57% in perimembranous VSD (p-VSD) and 64% in muscular VSD (m-VSD) patients. Initial diagnosis age, defect size, aneurysms tissue of the ventricular membranous septum (ATVMS), pulmonary hypertension (PH), and left ventricular diastolic dimension (LVDD) were statistically significant. Defect size, ATVMS and LVDD were determined by the Logistic Regression model as representative factor. P-VSD and m-VSD model had areas under the ROC curves 0.854 and 0.898, respectively.

CONCLUSION

We inferred that defect size, ATVMS and LVDD were characteristic and representative predictors for spontaneous closure of VSD. And we summarized the prognostic factors and recommended a follow-up criteria to assist the pediatrician managing VSD children.

Evaluation of Ventricular Septal Defect with Special Reference to the Spontaneous Closure Rate, Subaortic Ridge, and Aortic Valve Prolapse II

The medical records of 2283 patients with ventricular septal defect (VSD) were reviewed to determine spontaneous closure, left ventricular-to-right atrial shunt, subaortic ridge, and aortic valve prolapse. One thousand eight hundred and twenty-three patients had been followed 1 month to 26 years (median 4 years) by echocardiography. Most of 460 patients could not be followed due to transportation of the institution. VSD was perimembranous in 68.8% (1255), trabecular muscular in 21.7% (395), muscular outlet in 6% (109), muscular inlet in 2.6% (48), and doubly committed subarterial in 0.9% (16). Defect size was classified in 66.8% (1218) as small, in 15.7% (286) as moderate, and in 17.5% (319) as large. VSD closed spontaneously in 18.8% (343 of 1823 patients) by ages 40 days to 24.9 years (median, 1.8 years). One hundred fifty-seven of 1255 perimembranous defects (12.5%) and 167 of 395 trabecular muscular defects (42%) closed spontaneously (p < 0.001). Defect size became small in 306 (16.8%) of patients with VSD at a median of 2.5 years. Aneurysmal transformation was detected in 32.9% (600), left ventricular-to-right atrial shunt in 9.7% (176), subaortic ridge in 2.6% (48) of 1823 patients who were followed. In 381 (20.9%) of the 1823 patients, the VSD had been closed by a surgical or transcatheter technique. Surgery is required in one-fifth of patients with subaortic ridge or aortic valve prolapse. In conclusion, isolated VSDs are usually benign abnormalities that tend to shrink and close spontaneously.

A review of spontaneous closure of ventricular septal defect

Ventricular septal defect (VSD) is the most common congenital heart malformation and can be detected during the prenatal and postnatal period, in childhood, and in adulthood. Spontaneous closure of VSD can be determined through a variety of methods-echocardiography, Doppler color flow imaging, angiography, auscultation, and cardiac catheterization-and can be proven by pathological evidence at necropsy. There are two major types of VSD, membranous and muscular, as well as the perimembranous variety, which comprises variable portions of the adjacent muscular septum but lacks the membranous septum. VSD appears either as an isolated cardiac defect without other abnormalities or with several complex malformations. It has long been recognized that VSD can close spontaneously, but the incidence of spontaneous VSD closure is still uncertain. Since necropsy study of the hearts with VSD has rarely been reported, information on morphological features of spontaneous VSD closure remains limited. In addition, the mechanisms for spontaneous VSD closure are not fully understood. Herein, we present a brief review of the incidence of spontaneous VSD closure, morphological characteristics of the closure, and the main mechanisms responsible for the closure.

Congenital heart defects and maternal fever: systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyze the relation between maternal fever in the first trimester and congenital heart defect (CHD) in offspring.

STUDY DESIGN

We searched PubMed (1977-2012), Embase (1974-2012) and the Cochrane Library (2012) databases to identify relevant articles. Random effects model were performed, with the conduction of subgroup analysis.

RESULT

Meta-analysis yielded a pooled odds ratio of 1.53 (95% confidence interval=1.36 to 1.73) for the magnitude of the relation between maternal fever in the first trimester and CHD in offspring. As to subgroup analysis, it is associated with ventricular septal defects (VSDs) and right obstructive defects.

CONCLUSION

Our analysis suggests that maternal fever in the first trimester is the risk factor of congenital heart diseases in offspring. Through the subgroup analysis, we find that exposure to maternal fever is the risk factor of VSD and right obstructive defects.

Natural history of prenatal isolated muscular ventricular septal defects

OBJECTIVE

To evaluate the natural history of isolated muscular ventricular septal (m-VSD) defects during gestation and up to 1 year postnatally, as well as the association with chromosomal anomalies.

MATERIAL AND METHODS

Between August 2007 and July 2012, 76 fetuses with isolated m-VSDs represented the study population. The following variables were evaluated: site and size of the m-VSDs, presence of chromosomal anomalies, pregnancy outcome, and spontaneous closure rate from diagnosis up to 1 year postnatally.

RESULTS

Of the 76 cases with m-VSD, 1 fetus died after birth and 31 cases were lost to follow-up after birth. Thus, a total of 44 fetuses reached their first year of postnatal life, and these cases were available for analysis. Three (6.8%) of 44 defects closed spontaneously in utero, 33 (75%) closed within 1 year, and 8 (18.2%) remained patent. Overall, spontaneous closure occurred more frequently in the apical defects, but no significant difference was found for spontaneous closure between the mid-muscular and apical defects (p>0.05). Also, 83.8% (36 of 44) of defects ≤3 mm closed during gestation or the first year of life.

CONCLUSION

We infer that m-VSDs have a high spontaneous closure rate during the first year of life. Also, small m-VSDs frequently close spontaneously.

Prevalence of congenital heart disease at live birth: an accurate assessment by echocardiographic screening

AIM

To determine the true prevalence of congenital heart disease (CHD) at live birth using echocardiographic screening.

METHODS

A total of 5190 consecutive newborns from two secondary hospitals were included. Each neonate had a complete clinical evaluation with echocardiographic diagnosis at average 47 h of age. Newborns with persistent CHD underwent at least 4 months of follow-up, and the temporal trend of prevalence of mild CHD was assessed.

RESULTS

Overall live birth prevalence of CHD was 26.6‰ (severe 3.5‰, moderate 5.4‰ and mild 17.7‰), and prevalence of CHD that could be detected by clinical evaluation was 12.1‰. The most common CHD was ventricular septal defect (VSD, 17.3‰), followed by atrial septal defect (ASD, 6.2‰), patent ductus arteriosus (PDA, 1.3‰), tetralogy of Fallot (TOF, 0.4‰), single ventricle (SV, 0.4‰), atrioventricular septal defect (AVSD, 0.2‰) and double outlet right ventricle (DORV, 0.2‰). Female predominance was observed in mild CHD (VSD, ASD), and male predominance was observed in severe CHD. The prevalence of CHD was reduced to 19.5‰ at the 4-month follow-up, which was largely caused by spontaneous closure rate of muscular VSD.

CONCLUSION

Prevalence of CHD determined by echocardiography screening was higher but more accurate than that obtained from birth defect registries.