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CLINICAL STUDY: CONGENITAL HEART DISEASE

Long-term outcome of patients with ventricular septal defect considered not to require surgical closure during childhood

Harald M. Gabriel, MD^*, Maria Heger, MD^*, Petra Innerhofer, MD^*, Manfred Zehetgruber, MD^*, Gerald Mundigler, MD^*, Maria Wimmer, MD, Gerald Maurer, MD, FACC^* and Helmut Baumgartner, MD, FACC^*,*

^* Department of Cardiology, University of Vienna, Vienna, Austria
Department of Pediatric Cardiology, University of Vienna, Vienna, Austria

Manuscript received August 21, 2001; revised manuscript received December 12, 2001, accepted December 18, 2001.

^* Reprint requests and correspondence: Dr. Helmut Baumgartner, Department of Cardiology, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
helmut.baumgartner{at}univie.ac.at

OBJECTIVES: The purpose of the study was to assess the long-term outcome of patients with small ventricular septal defects (VSDs) considered not to require surgical closure during childhood.

BACKGROUND: Although patients with small VSDs have generally been considered not to require surgery, more recent data suggest that a significant percentage of these patients develop serious problems during adult life.

METHODS: A total of 229 consecutive patients (115 females) with a VSD considered too small to require surgery during childhood as defined by normal pulmonary artery pressure, less than 50% shunt, pulmonary vascular resistance 200 dynes·s·cm^–5, no VSD-related aortic regurgitation (AR), and no symptoms and who had no additional hemodynamically relevant heart defect were followed in an adult congenital heart disease program. Physical examination, electrocardiography, and echocardiography were performed in all patients in one- to three-year intervals; exercise tests and Holter monitoring were performed in 140 and 127 patients, respectively.

RESULTS: Follow-up was completed in 222 patients (97%). Mean age at last visit was 30 ± 10 years. Spontaneous VSD closure was observed in 14 patients (6%). No patients died, four patients (1.8%) had an episode of endocarditis, of whom two required aortic valve replacement, and one additional patient (0.4%) had surgical closure for hemodynamic reasons. For 118 patients who entered the study between 1993 and 1996 and were prospectively followed for 7.4 ± 1.2 years, event-free survival with end points defined as death, endocarditis or heart surgery was 99.1 ± 0.8% at three years, 96.5 ± 1.7% at six years and 95.5 ± 1.9% at eight years. At last visit, 94.6% of all patients studied were symptom free. Left ventricular (LV) size by echocardiography was normal in 198 (89%) patients, borderline in 23 patients and definitely enlarged in only one patient. None had systolic LV dysfunction, and pulmonary artery pressure (PAP) was normal in all patients. Mean exercise capacity was 92 ± 21% of expected, and 87% of patients had no arrhythmias on Holter monitoring, with the remainder showing benign rhythm disorders.

CONCLUSIONS: Outcome in well-selected patients with a small VSD is good. Surgical closure does not appear to be required during childhood as long as left-to-right shunt is <50% and signs of LV volume overload are absent, when PAP is not elevated, and no VSD-related AR or symptoms are present.

Abbreviations and Acronyms   LV-RV gradient   AR   aortic regurgitation   ECG   electrocardiogram   LV   left ventricle/ventricular   LVEDD   left ventricular end-diastolic diameter   LVEDDi   left ventricular end-diastolic diameter index   LV-RV gradient   left ventricular to right ventricular systolic gradient   PAP   pulmonary artery pressure   Qp/Qs   shunt ratio (pulmonary to systemic flow)   VSD   ventricular septal defect

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