Incidence of Spontaneous Closure of Outlet Ventricular Septal Defect

Ventricular septal defect associated with aortic regurgitation and ascending aortic aneurysm: a case report

INTRODUCTION

Ventricular septal defect (VSD) is one of the most common congenital cardiac anomalies. Patients with perimembranous VSD may have aortic regurgitation (AR) secondary to prolapse of the aortic cusp.

CASE PRESENTATION

We present a case of 23-year-old White man with VSD, AR and ascending aortic aneurysm. The patient presented to outpatient clinic with weakness and gradual worsening shortness of breath for the past 5 years. Clinical examination revealed regular heart rhythm and loud continuous systolic-diastolic murmur (Lewin's grade 6/6), heard all over the precordium, associated with a palpable thrill. The ECG showed right axis deviation, fractionated QRS in V1 and signs of biventricular hypertrophy. The chest X-ray showed cardiomegaly. Transthoracic and transesophageal echocardiograms showed a perimembranous VSD with moderate restrictive shunt (Qp/Qs = 1.6), aortic regurgitation (AR), and ascending aortic aneurysm. Other clinical and laboratory findings were within normal limits.

CONCLUSIONS

Perimembranous VSD, may be associated with aortic regurgitation and ascending aortic aneurysm as secondary phenomenon if it is not early diagnosed and successfully treated.

Survival and outcomes of isolated neonatal ventricular septal defects: A population-based study from a middle-income country

Background and Aims

Limited data on the survival and outcomes of ventricular septal defect (VSD) in middle-income countries are available. Hence, this study aims to determine the survival and factors associated with mortality among neonatal VSD.

Materials and Methods

This is a retrospective, population based study of neonates with isolated VSD born between 2009 and 2019. Kaplan-Meier analysis was used to estimate the overall survival. Cox regression analysis was used to determine factors associated with mortality.

Results

There were 726 patients studied, with 82 (11%) of them having trisomy 21. The median age of diagnosis and follow-up was 5 days (interquartile range [IQR]: 2-10 days) and 2.3 years (IQR: 0.6-4.8 years), respectively. Of 726, 399 (55%) were perimembranous, 218 (30%) muscular, and 109 (15%) outlet VSD. VSD was small in 309 (42%), moderate in 337 (46%), and large in 80 (11%). Of 726 patients, 189 (26%) had congestive heart failure (CHF) and 52 (7.2%) developed pulmonary hypertension (PHT). Interestingly, one-third of CHF and PHT resolved over time during follow-up. Only 1 (0.1%) patient had infective endocarditis, 38 (5.2%) developed aortic regurgitation, and none had Eisenmenger syndrome. Overall, 149 (20%) needed surgery, 399 (55%) spontaneously closed, and 178 (25%) remained small. The mortality rate was 3.9% (28), 16 (57%) preoperatively, and 11 (39%) due to pneumonia. Trisomy 21, PHT, and birth weight <2.5 kg were independent factors for mortality with an adjusted hazard ratio of 6.0 (95% confidence interval [CI]: 2.1-16.9), 3.2 (95% CI: 1.2-8.4), and 3.6 (95% CI: 1.7-7.8), respectively. The overall survival at 1, 5, and 10 years was 96% (95% CI: 95-98), 95% (95% CI: 94-97), and 95% (95% CI: 94-97), respectively.

Conclusions

Despite limited pediatric and congenital cardiac services in middle-income countries, the overall survival of neonatal VSD is good, with poor outcomes in small infants, PHT, and trisomy 21.

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.

Ventricular septal defect and aortic valve regurgitation: pathophysiology and indications for surgery

As the velocity of a fluid increases a low-pressure zone is created, this is the Venturi effect and it explains the pathogenesis of aortic valve prolapse (AVP) and aortic insufficiency (AI) that is observed in a subset of patients with a ventricular septal defect (VSD). The VSDs complicated by AI are restrictive with high velocity shunting through the VSD, creating a low-pressure zone that impacts the adjacent aortic valve cusp resulting in AVP and subsequent AI. AVP and AI are therefore acquired lesions. AI is absent at birth because the forces necessary to create the low-pressure zone within the restrictive VSD do not exist in utero. The risk of development of AI increases during childhood, peaking at 5 to 10 years of age. VSD closure eliminates the low-pressure zone that is the cause of ongoing aortic valve cusp deformity and, if performed early, prevents development of AI. Patients with a subarterial VSD and AVP should undergo surgery to prevent the development of AI because this complicates about half of subarterial VSDs with AVP and spontaneous closure is rare. Patients with perimembranous VSDs with AVP should be followed with serial echocardiography and undergo VSD closure if more than trivial AI develops.

Spontaneous closure of ventricular septal defects followed up from <3 months of age

BACKGROUND

This study evaluates the incidence and timing of spontaneous closure (SC) of ventricular septal defect (VSD) using Doppler color flow mapping.

METHODS

A total of 225 infants (mean age 30 days) were diagnosed with uncomplicated VSD: 31 (14%) subpulmonary VSD, 159 (70%) perimembranous, and 35 (16%) muscular. The patients were divided into two groups according to the presence or absence of congestive heart failure (CHF). SC was confirmed with color Doppler.

RESULTS

Surgical closure was performed in 59 patients (26%). SC occurred in 107 patients (48%); three (10%) of 31 with subpulmonary VSD, 75 (47%) of 159 with perimembranous VSD, and 29 (83%) of 35 with a muscular VSD. Average age at SC was 19 months. In three SC patients with a subpulmonary VSD, there was no aortic valve prolapse and no aortic regurgitation. SC occurred in 96% of SC patients with a perimembranous VSD by the age of 6 years, and in 93% of those with a muscular VSD by the age of 3 years. In patients without CHF, the rate of SC was 72%; 23% in subpulmonary VSD, 74% in perimembranous, and 85% in muscular. SC occurred in only 23% of patients with a perimembranous VSD with CHF. Mean age at the final examination was 6.9 years in 59 patients with a VSD remaining open, and 63% of patients with a perimembranous VSD remaining open had an aneurysm of the ventricular membranous septum.

CONCLUSIONS

The SC rate of VSD by mean age of 6.9 years was 48%, but it was 72% in patients without CHF. In patients with CHF, SC was seen only in patients with a perimembranous VSD. The rate of SC was 10% in subpulmonary VSD. The authors contend that SC probably occurred by growth of muscular septum surrounding VSD. Muscular VSD spontaneously closed earlier than perimembranous VSD.

Severity Indices of Right Coronary Cusp Prolapse and Aortic Regurgitation Complicating Ventricular Septal Defect in the Outlet Septum-Which Defect Should Be Closed?-

BACKGROUND

The factors that may determine the evolution of right coronary cusp prolapse (RCCP) and regurgitation (AR) associated with a ventricular septal defect in the outlet septum (outlet VSD) have not been clarified.

METHODS AND RESULTS

The Doppler echocardiograms of 316 patients were grouped according to both the development of RCCP, and the values of the right coronary cusp deformity index (RCCD) and the right coronary cusp imbalance index (R/L). All detected AR was </= slight, and not progressive in patients with both RCCD <0.30 and R/L <1.30. Moderate AR was detected in patients with either RCCD >/=0.30 or R/L >/=0.30. Rupture of the sinus of Valsalva was identified in patients with RCCD >/=0.30. A significantly large number of patients with both RCCD >/=0.30 and R/L >/=1.30 (p<0.01), and a few patients with either RCCD >/=0.30 or R/L >/=0.30 underwent aortic valvuloplasty or replacement. Operative outcome for AR </= slight was good.

CONCLUSIONS

There is no need to close an outlet VSD with RCCP when the RCCD <0.30 and R/L <1.30 as long as the AR remains trivial, but such defects should be closed when the RCCD is >/=0.30 or R/L >/=1.30.

Eccentric aortic regurgitation in patients with right coronary cusp prolapse complicating a ventricular septal defect

To analyze the clinical significance of eccentric aortic regurgitation (AR) complicating the right coronary cusp prolapse associated with a ventricular septal defect (VSD), the Doppler echocardiograms of 129 patients were reviewed. In 102 patients, AR was classified as mild and in 27 patients it was classified as moderate. Eccentric AR was defined as the jet distributing in an eccentric direction. In 15 patients of the moderate group, AR was already moderate at the initial examination and of these, the AR was eccentric in 14 and central in 1. In 12 patients who initially had mild AR, it became moderate during follow-up. In 7 patients with mild, central AR, 6 worsened to central moderate AR and 1 evolved to eccentric moderate AR. Eccentric mild AR patients all developed eccentric moderate AR. Within the mild AR group, 5 of 9 patients with eccentric AR progressed from mild to moderate, whereas only 7 of 105 patients with central AR did so (p<0.01). In conclusion, eccentric AR may be an advanced finding of the AR associated with right coronary cusp prolapse in some patients, but in others eccentric AR is highly likely to progress and is malignant.

Left ventricular performance during pregnancy in patients with repaired tetralogy of Fallot: prospective evaluation using the Tei index

Little is known about the influence of hemodynamic changes on ventricular performance during pregnancy in patients with congenital heart disease. A prospective evaluation was made of 17 pregnancies in 11 women with repaired tetralogy of Fallot (ToF). Twenty age-matched non-pregnant women and 41 stable pregnant women without heart disease were studied as controls. Blood pressure (BP), heart rate (HR), left ventricular end-diastolic dimension (LVEDD) and ejection fraction (LVEF), and the Tei index were measured before pregnancy; during the 1st, 2nd, and 3rd trimesters; and after delivery. BP and HR gradually increased during the pregnancy in both groups. The LVEDD in the controls increased throughout the gestation period, then decreased after delivery. In contrast, the LVEDD in the ToF was significantly smaller than that of the controls, and no such increase was observed. The LVEF did not change throughout pregnancy or after the delivery in either group. Although the Tei index of the controls did not change throughout the pregnancy, in the ToF group it was significantly increased in the 2nd and 3rd trimester and then decreased after delivery. These findings suggest that subclinical left ventricular intolerance for volume overload, probably because of the smaller LVEDD, may exist during pregnancy in patients with a repaired ToF.