- Children with small VSDs are asymptomatic and have excellent long-term prognoses. Neither medical therapy nor surgical therapy is indicated. Antibiotic prophylaxis against endocarditis should be provided at the time of dental or surgical procedures likely to produce bacteremia. For more information, see Antibiotic Prophylactic Regimens for Endocarditis.
- In children with moderate or large VSDs, a trial of medical therapy is indicated to manage symptomatic CHF because many VSDs may become smaller with time. Therapies may include the following:
- Increased caloric density of feedings to ensure adequate weight gain. On occasion, oral feeds must be supplemented with tube feeds because a baby in CHF may be unable to consume adequate calories for appropriate weight gain.
- Diuretics (eg, furosemide) may be used to relieve pulmonary congestion. Furosemide is usually given in a dosage of 1-3 mg/kg/d in 2 or 3 divided doses. Long-term furosemide treatment results in hypercalcemia and renal damage and electrolyte disturbances
- Captopril 0.1-0.3 mg/kg given every 8 hours can be useful to reduce systemic afterload. The mechanism of action of angiotensin-converting enzyme (ACE) inhibitors is to reduce both the systemic and pulmonary pressures (more so of the latter), and this results in reducing the left to right shunt.
- Digoxin 5-10 mcg/kg/d may be indicated if diuresis and afterload reduction do not relieve symptoms adequately.
- Indications for surgical repair
- Uncontrolled CHF, including growth failure and recurrent respiratory infection is an indication for surgical repair. Neither the age nor the size of the patient is prohibitive in considering surgery.
- Large, asymptomatic defects associated with elevated PA pressure are often repaired when infants are younger than 1 year.
- Surgical repair is indicated in older asymptomatic children with normal pulmonary pressure if pulmonary to systemic flow is greater than 2:1.
- Prolapse of an aortic valve cusp. Early repair may prevent progression of the aortic insufficiency.
- Short-term results of video-assisted cardioscopy for intraventricular repair of VSD have led to its wide adoption as a means to reduce surgical trauma. Short-term results are excellent.
- Long-term follow-up is necessary.
- Most perimembranous and inlet defects are repaired by transatrial surgical approach.
- Defects in the outlet septum are approached through the pulmonary valve.
- Multiple muscular defects, especially near the apex, pose a difficult problem. Initial pulmonary banding or LV approach through an apical left ventriculotomy and closing the defect by a single patch are the standard approaches.
- Transcatheter therapy remains an experimental approach.
- A hybrid operation is a joint procedure involving the interventional cardiologist and the cardiac surgeon who concomitantly optimize surgical management of complex congenital heart disease. This approach may be used for multiple VSDs where the perimembranous VSD is repaired surgically and the muscular VSDs are closed by using a transcatheter device.
- A murmur of a residual VSD is not infrequent. Selective use of intraoperative TEE to assess closure may be useful.
- Decisions regarding reoperation are based on symptoms, left heart size, pulmonary pressure, and degree of shunting.
- Right bundle-branch block (RBBB) is common and may be caused by ventriculotomy or direct injury to the right bundle itself.
- Complete heart block can rarely occur and is associated with late mortality.
- LV dysfunction may occur after left ventriculotomy to close a muscular VSD.
- Ventricular arrhythmia can be a late problem.