Management of Closed Subaortic Aneurysmal Perimembranous VSD
Introduction to Management
- The European Society of Cardiology recommends surgical closure for a closed (aneurysmal) perimembranous VSD to prevent life-threatening complications, including aortic valve prolapse with progressive aortic regurgitation, infective endocarditis, aneurysm rupture, and right ventricular outflow tract obstruction, even in asymptomatic patients 1, 2, 3, 4
Key Complications Requiring Intervention
- Infective endocarditis risk increases 6-fold compared to the general population, with 13.7% of patients experiencing bacterial endocarditis, according to the European Heart Journal 1
Surgical Indications
- The American College of Cardiology recommends surgery for patients with VSD-associated prolapse of an aortic valve cusp causing progressive aortic regurgitation, and for asymptomatic patients with evidence of LV volume overload attributable to the VSD 1, 2, 3, 4, 5
- The European Society of Cardiology suggests surgery for symptomatic patients with left-to-right shunting and no severe pulmonary vascular disease 1, 2, 4, 5
Diagnostic Evaluation
- Echocardiography is the key diagnostic modality and must assess location, number, and size of VSD, presence and extent of aneurysmal tissue, aortic valve morphology and degree of prolapse, severity of aortic regurgitation, LV volume overload, and systolic/diastolic function, according to the European Heart Journal 1, 2, 4, 5
Contraindications to Surgery
- The American College of Cardiology recommends avoiding surgery in patients with Eisenmenger syndrome with exercise-induced desaturation, and severe pulmonary vascular disease with PA systolic pressure >2/3 systemic and pulmonary vascular resistance >2/3 systemic 1, 2, 3, 4, 5, 6, 7
Surgical Indications for Subaortic VSD with Right Coronary Cusp Prolapse
Immediate Surgical Indications
- Surgical closure is reasonable when worsening aortic regurgitation is caused by the VSD, regardless of hemodynamic significance, representing a Class IIa recommendation from the 2018 ACC/AHA guidelines, as stated by the American College of Cardiology 8
Hemodynamic Indications
- Qp:Qs ≥2.0 with clinical evidence of LV volume overload, as recommended by the American Heart Association 9
- Qp:Qs ≥1.5 with evidence of LV systolic or diastolic failure, as recommended by the American Heart Association 9
- PA systolic pressure <50% of systemic pressure AND pulmonary vascular resistance <1/3 systemic resistance when Qp:Qs ≥1.5, according to the American College of Cardiology 8
Absolute Contraindications to Surgery
- VSD closure should not be performed when PA systolic pressure exceeds 2/3 systemic AND pulmonary vascular resistance exceeds 2/3 systemic, as stated by the American College of Cardiology 8