Aortic Valve Prolapse Associated With Outlet-Type Ventricular Septal Defect

A Retrospective Study in Occluding Sub-arterial Ventricular Septal Defect

To assess the safety and effectiveness of utilizing eccentric occlusion for the treatment of sub-arterial ventricular septal defects, we performed a retrospective study on the classification and analysis of relevant cases. A total of 105 patients with a minimally invasive incision were enrolled in this study, from April 2018 to September 2022. All patients underwent treatment of transthoracic sub-arterial ventricular septal defect occlusion. We analyzed the causes of closure failure, indication, and complication. Briefly, the closure device was successfully implanted in 78 cases (74.2%) with a mean age of 31.4 ± 31.8 months, VSD size of 4.3 ± 0.9 mm, and device size of 6.0 ± 1.1 mm. However, 27 cases (25.8%) required cardiopulmonary bypass due to failure of occlusion. The reasons for failure included 13 cases with worsened aortic regurgitation, two cases with worsened aortic valve prolapse, one case with worsened mitral regurgitation, eight cases with significant residual shunt, and three cases with deviated occlusion morphology. During the 1-36-month follow-up visit, no cases experienced displacement of the eccentric umbrella, shedding, or arrhythmia. All residual shunts resolved during the visit. We concluded that occlusion for sub-arterial VSD has sufficient security and feasibility, under the strict control of surgical indications, appropriate choice of occluder and precise perioperative management.

Progression of aortic regurgitation following transcatheter closure of intracristal ventricular septal defects in children: a mid- to long-term follow-up study

Background

Early surgical closure is warranted to prevent aortic valve lesion and aortic regurgitation (AR) in intracristal ventricular septal defects (icVSDs). Experiences for transcatheter device closure of icVSDs are still limited. Our objectives are to investigate AR progression following transcatheter closure of icVSDs in children and to explore the risk factors for AR progression.

Methods and results

From January 2007 to December 2017, 50 children with icVSD who had successfully undergone transcatheter closure were enrolled. With 4.0 (interquartile range: 3.0-6.2) years of follow-up, AR progression was observed in 20% (10/50) of patients after icVSD occlusion, among which 16% (8/50) remained in mild level and 4% (2/50) evolved to moderate. None progressed to severe AR. Freedom from AR progression was 84.0%, 79.5%, and 79.5% at 1, 5, and 10 years of follow-up. A multivariate Cox proportional-hazards model revealed that x-ray exposure time [hazard ratio (HR): 1.11, 95% confidence interval (CI): 1.04-1.18, P = 0.001] and the ratio of pulmonary to systemic blood flows (HR: 3.38, 95% CI: 1.11-10.29, P = 0.032) were independent predictors for AR progression.

Conclusions

Our study suggested that transcatheter closure of icVSD in children is safe and feasible in mid- to long-term follow-up. No serious AR progression occurred after icVSD device closure. Greater left-to-right shunting and longer x-ray exposure time were both risk factors for AR progression.

Double outlet right ventricle in adults: Anatomic variability, surgical treatment, and late postoperative complications

Double outlet right ventricle (DORV) is a highly complex congenital heart disease (CHD) entity, gaining increasing interest due to the rapid progress of cardiac surgery. The number of patients operated for this congenital defect has been growing since 1980s and over following decades with active transitioning of this cohort into the adult medicine. However, the diversity of initial anomaly and performed interventions makes challenging the management of these patients. This is particularly important in the regions where specialized adult CHD cardiology still remains underdeveloped. In this review, we observe the basic principles of DORV nomenclature, main types of the operations and possible late complications. The article focuses on adult patients and offers illustrations from clinical practice.

Postoperative Aortic Regurgitation in Outflow Ventricular Septal Defect: Determinants of Outcome

Aortic cusp prolapse is an acquired complication and usually precedes the development of aortic regurgitation (AR) in unoperated outflow ventricular septal defect (VSD). However, its impact on postoperative AR-progression is unknown. 161 patients with outflow-VSD and AR who underwent surgery between 2006 and 2012 were studied retrospectively. 31 patients without prolapse (group-I), 87 with only right coronary cusp (RCC) (group-II), 43 with noncoronary cusp (NCC) prolapse (group-III: 23 only NCC (IIIa), 20 both NCC-RCC (IIIb)) were followed postoperatively for a mean 6.05 ± 2.4 years (range 3-12 years). Moderate or severe-AR was present in 4.2%, 36.8%, 52.2% and 80% preoperatively; in 3.2%, 10.3%, 39.1% and 30% patients at follow-up in group-I, II, IIIa, and IIIb, respectively. Although freedom from significant-AR (moderate or severe AR) or aortic valve replacement (AVR) at 10 years was lesser in subaortic-VSD than subpulmonic-VSD (64.3 ± 7.5% vs 87.9 ± 3.6%; P = 0.02), the difference was not significant when compared within prolapse groups (80 ± 8% vs 88.7 ± 4.0%, P = 0.28 in group-II; 40.7 ± 11.8 vs 70 ± 14.5%, P = 0.48 in group-III). The significant-AR or AVR free survival in patients with trivial or mild preoperative-AR was not significantly different between prolapse groups (98.2 ± 1.8% vs 75 ± 21.7% in group-II and III respectively; P = 0.85). However, in those with moderate or severe preoperative-AR it was significantly lesser in group-III than II (30.1 ± 9.8% vs 65.6 ± 8.4%, respectively; P = 0.04). Group-III, compare to group-II, had 3.28 and 5.24-time risk of development of significant-AR or requirement of AVR, respectively. Prolapse of NCC alone or in addition to RCC prolapse has unfavourable impact on the postoperative outcomes, especially in subaortic-VSD after development of more than mild AR preoperatively.

Outlet Ventricular Septal Defect in an Elderly Male

Ventricular septal defect (VSD) is the most common congenital cardiac anomaly in children and the second most common congenital cardiac anomaly in adults. The hemodynamic compromise associated with VSD is due to the shunt formation created by the abnormal communication between the right and left ventricles. While 85%-90% of small VSDs close spontaneously during the first year of life, some do not close spontaneously. If spontaneous closure does not occur during childhood, a VSD may persist into adulthood and may first be recognized after the development of a complication. We present a case of outlet VSD with secondary aortic insufficiency due to the prolapse of the aortic valve leaflet, especially in the right coronary cusp (RCC) sparing the left coronary cusp. RCC prolapse is an important finding in outlet VSD as the prolapse has the potential to cause permanent aortic insufficiency and closure is indicated regardless of the size of VSD.

Outflow Ventricular Septal Defect with Aortic Regurgitation: Optimal timing of Surgery?

BACKGROUND

Ideal time of surgery still remains controversial in outflow ventricular septal defect (VSD) with aortic regurgitation (AR). We aimed to identify the prevalence and predictors of postoperative AR progression.

METHODS

154 patients with outflow-VSD and AR who underwent VSD surgery between 2006 and 2012 were studied retrospectively.

RESULTS

Total 80 patients with subpulmonic-VSD and 74 with subaortic-VSD were followed-up for mean 6.32+/-2.27 years (range 3-12 years). Of them, 100 had trivial to mild (group-A) and 54 had moderate to severe preoperative-AR (group-B). At follow-up, There was no significant worsening of mean residual AR in group-A (p=0.16) and subpulmonic-VSD of group-B (p=0.083). However, it worsened significantly in subaortic-VSD (1.85+/-0.87 vs 2.21+/-1.08, p=0.005) of group-B. Only 2 (both had subaortic-VSD) patients of group-A developed moderate AR and none required aortic valve replacement (AVR), while 23 (42.60%) of group-B patients developed moderate or severe AR and 7 (30.4%) of them required AVR. Moreover, all who needed AVR had subaortic-VSD and had undergone valvuloplasty during VSD-closure. The 10 years freedom from moderate or severe-AR was significantly lower in group-B than group-A in both VSDs (subaortic-VSD 42.5+/-10.7% vs 89.3+/-8.1%, p<0.01; subpulmonic-VSD 66.7+/-10.3% vs 100%, p<0.01). On multiple regression analysis, postoperative residual-AR was the only predictor of AR-progression (standardized coefficients =0.48; p<0.001) at follow-up.

CONCLUSIONS

Mild preoperative-AR rarely progressed after VSD-repair. However, worsening of AR could not be prevented effectively, even with valvuloplasty, after the development of moderate or severe AR. Mild or more postoperative residual-AR need close follow-up, especially in subaortic-VSD.

Safety and efficacy of transcatheter closure of outlet-type ventricular septal defects in children and adults with Amplatzer Duct Occluder II

BACKGROUND/PURPOSE

Outlet-type VSD is frequently associated with aortic valve prolapse that surgery is frequently required. The literature regarding outcomes of transcatheter closure of outlet-type VSDs is scant. This study was conducted to know the safety and efficacy of transcatheter closure of outlet-type ventricular septal defects (VSDs) with Amplatzer Duct Occluder II (ADO II).

METHODS

Medical records of patients underwent attempted transcatheter closure of outlet-type VSD with ADO II between October 2013 and August 2019 were retrospectively reviewed.

RESULTS

Among 49 patients, transcatheter closure was successful in 45 (91.8%; 33 males and 12 females; mean [± standard deviation] age and body weight: 15.8 (±17.7) years and 36.6 (±23.3) kg, respectively). The median VSD diameter was 4.0 mm (range: 1.2-6.0 mm). Device closure failed in four because the sheath could not be advanced through a prograde or retrograde route in one patient, occluder embolization in the two patients, and failed right ventricular disc anchoring in one patient. After a mean follow-up of 22.7 months (range: 0.3-51.1 months), only nine (20.0%) patients had increased severity in aortic regurgitation (AR) on the echocardiography. Preprocedural AR decreased in severity or even disappeared in 11 (24.4%) patients. No heart block or device failure occurred during follow-up. A trivial-to-small residual shunt was detected in 19 patients (42.2%) in the most recent echocardiography.

CONCLUSION

Transcatheter closure of outlet-type VSDs with ADO II is feasible. Although no significant aggravation of AR was observed in the short-to-mid-term follow-up, long-term follow-up is mandatory.

Outcomes of closure of doubly committed subarterial ventricular septal defects in adults

BACKGROUND

Outcome data of doubly committed subarterial ventricular septal defect closure in adults are limited.

METHODS

A review was made of the inpatients >18 years of age who underwent doubly committed subarterial ventricular septal defect closure between June 2010 and June 2017.

RESULTS

The patients were categorised into two groups: The valve intervention group consisted of 31 patients who underwent aortic valvuloplasty, aortic valve replacement, or repair of sinus Valsalva aneurysm in addition to doubly committed subarterial ventricular septal defect closure; non-valvular intervention group comprised 58 patients who underwent only doubly committed subarterial ventricular septal defect closure. The groups did not differ by sex and age. Patients in the valve intervention group, with a larger ventricular septal defect size, were shorter and tended to be lighter. The valve intervention group had more patients with pneumonia perioperatively. No infective endocarditis and reoperation were noted during the study period. At last follow-up, 91 and 96.6% of the studied patients were free from left ventricle dilation and pulmonary hypertension. In patients without pre-operative aortic regurgitation, 12 developed new mild aortic regurgitation during the follow-up.

CONCLUSIONS

About 34.8% of adult patients with doubly committed subarterial ventricular septal defect required concurrent intervention on aortic valve or sinus Valsalva aneurysm. The midterm results of doubly committed subarterial ventricular septal defect closure in adult patients were favourable. However, the incidence of new mild aortic regurgitation after ventricular septal defect closure was high (27.3%). Long-term follow-up of aortic regurgitation progression is needed.

Doubly committed Subarterial Ventricular Septal defect repair: An experience of 51 cases

Objective:

To review the surgical outcome of doubly committed subarterial (DCSA) ventricular septal defect repair.

Method:

Data of 51 patients of doubly committed sub arterial Ventricular septal defect from January 2012 to June 2017 that were referred to Chaudhary Pervaiz Elahi institute of Cardiology Multan was retrospectively reviewed using electronic database. All patients were operated by first author. In our study, we segregated patients into four main groups depending on presence or absence of aortic structural defect and degree of aortic valve regurgitation. Group-A comprised of nineteen (37%) patients who neither had aortic structural nor functional abnormality while Group-B had six (11.7%) patients, having aortic valve cusp prolapse without aortic regurgitation. Group-C and Group-D consists of seventeen (33.3%) and nine (17.6%) patients respectively depending upon degree of aortic regurgitation. Furthermore, six (11.7%) patients among these 51 had associated defects as well.

Results:

Group-A patients had no aortic valve regurgitation post operatively and at follow up of 22.6 months (1.8 years) as well. In Group-B, aortic valve was not addressed and aortic regurgitation was also not present post operatively or on follow up of 33.6 months (2.8 years). Similarly, in Group-C aortic valve was not addressed, these patients also did not show progression of disease on regular follow up of 18 months (1.5 year). While, in Group-D, eight patients underwent aortic valve repair and one patient had aortic valve replacement. Aortic regurgitation improved significantly in all patients of this group and remained unchanged on follow up of 22.7 months (1.8 years).

Conclusion:

Early closure of doubly committed subarterial ventricular septal defect with appropriate management of aortic valve disease can halt the process of disease progression.

Factors associated with aortic root dilatation after surgically repaired ventricular septal defect

BACKGROUND

Aortic root dilatation (ARD) in congenital heart disease is related to aortic aneurysm, rupture, and dissection. This study aimed to investigate the factors associated with ARD in patients with surgically repaired ventricular septal defect (VSD).

METHODS

This cross-sectional study included 152 patients with surgically repaired VSD. Two definitions of ARD were used: (1) observed Valsalva diameter to body surface area (BSA) ratio >2.1 cm/m² and (2) absolute value of Valsalva diameter ≥4.0 cm. Odds ratios (ORs) and 95% confidence intervals (CIs) of ARD presence were calculated using multivariate logistic regressions.

RESULTS

The prevalence of ARD ranged between 8.6% and 32.9%. Using the definition of observed aortic root diameter/BSA >2.1 cm/m² , patients with nonsubarterial VSD type were more likely to have ARD (OR 5.65, 95% CI; 1.83-17.44, P=.003) than those with subarterial type, and patients with preoperative right- or noncoronary cusp prolapse (R/NCCP) were more likely to have ARD (OR 3.68, 95% CI; 1.20-11.23, P=.022) than patients without preoperative R/NCCP after adjustment for sex, age at repair (ie, shunt duration), VSD size, and postoperative follow-up period. Using the definition of absolute Valsalva diameter ≥4 cm, nonsubarterial VSD type and presence of R/NCCP were also significantly associated with ARD after adjustment for the same covariates.

CONCLUSIONS

Anatomical and morphological features (nonsubarterial type and presence of preoperative R/NCCP) are independently correlated with ARD in patients with VSD regardless of the different definitions of ARD. Patients with surgically repaired VSD may need careful monitoring for potential ARD development.

Precise moulded autologous pericardial configurations for aortic cusp reconstruction

OBJECTIVES

In order to facilitate surgical repair of complex aortic cusp deformities and restoration of aortic valve competence, new moulds were developed to shape the glutaraldehyde-treated autologous pericardium into precise cusp-like configurations that can be used in aortic cusp reconstruction.

METHODS

The new moulds embodied the natural geometry of single aortic cusps, and a series of moulds were made available to correspond with all potential aortic cusp sizes. Aortic valve reconstruction using moulded autologous pericardial cusps was performed in 2 patients (both males, aged 14 and 19 years) with large outlet-type ventricular septal defects, extensive deformation of prolapsed right coronary cusps and severe aortic valve insufficiency. In each patient, the diseased right aortic cusp was excised and was replaced by a moulded autologous pericardial cusp that equalled the size of adjacent undiseased native cusps.

RESULTS

Excellent coaptation with adjoining native aortic cusps could be readily observed and intraoperative transoesophageal echocardiography confirmed satisfactory aortic valve repair (aortic insufficiency <1+ and low-transvalvular gradients). Follow-up transthoracic echocardiography confirmed that aortic valve function remained stable in both patients 2 years postoperatively.

CONCLUSIONS

Initial clinical experience indicated that constructing geometrically perfect cusp-like configurations was uncomplicated and implantation of the moulded autologous pericardial cusps restored adequate aortic valve competence. We believe that the simplicity and reproducibility of this approach may assist in the dissemination of aortic cusp reconstruction procedures.

Frequency of Development of Aortic Valve Disease in Unrepaired Perimembranous Ventricular Septal Defects

We sought to determine the natural history of aortic valve disease in patients with unrepaired perimembranous ventricular septal defects (pVSDs) and to identify echocardiographic parameters predictive of increased risk of surgical repair of pVSD because of aortic valve disease. We retrospectively analyzed all echocardiograms of patients with a diagnosis of pVSD at our institution from January 1999 to January 2015. All available echocardiographic data were collected. Patients were excluded if there was another structural cardiac anomaly other than bicuspid aortic valve, small patent foramen ovale, or ductus arteriosus. The prevalences of aortic valve prolapse and regurgitation, as well as aortic valve disease progression, were determined. A total of 2,114 echocardiograms from 657 patients with unrepaired pVSD were reviewed. Median age at the time of echocardiogram was 1.9 years (interquartile range [IQR] 0.2 to 5.4). Median duration of follow-up was 1.7 years (IQR 0.2 to 7.4). pVSD-associated aortic valve disease prompted surgical intervention in 1.5% (10 of 657) of patients. Median age at the time of surgery was 4.8 years (IQR 1.7 to 8.4). A pVSD-to-aortic annulus diameter ratio of 0.66 ± 0.05 was present in 90% (9 of 10) of patients who underwent surgical closure because of pVSD-associated aortic valve disease. In conclusion, pVSD-associated aortic valve disease is uncommon, and progression of aortic regurgitation is rare. These data suggest that the majority of patients with pVSD do not require frequent follow-up and that frequent follow-up can be saved for a subset with echocardiographic markers placing them at higher risk of aortic valve diseases.

Transthoracic Subarterial Ventricular Septal Defect Occlusion Using a Minimally Invasive Incision

BACKGROUND

This study sought to investigate the feasibility of transthoracic occlusion of a subarterial ventricular septal defect using a minimally invasive incision.

METHODS

Between January 2009 and June 2014, we performed transthoracic subarterial ventricular septal defect occlusion for 81 patients via a minimally invasive incision. A special delivery sheath was used during surgery, and an eccentric occluder was implanted in the ventricular septal defect.

RESULTS

Successful defect closure was achieved in 74 cases, perioperative arrhythmia occurred in five cases, and a large pericardial effusion was observed in two cases. Open heart surgery was performed for two patients to repair postoperative dislocation of the occluder. Intraoperative conversion to surgical repair was required in seven cases. During one to five years of follow-up, there was no late occluder dislocation, residual leakage, or thrombus-related complications.

CONCLUSIONS

Transthoracic subarterial ventricular septal defect occlusion using a minimally invasive incision may be an alternative to open surgical repair in selected patients. doi: 10.1111/jocs.12754 (J Card Surg 2016;31:398-402).

Prognostic implications of initial echocardiographic findings in adolescents and adults with supracristal ventricular septal defects

BACKGROUND

Although surgery is recommended for pediatric patients with supracristal ventricular septal defects (sVSDs) to prevent progression of aortic regurgitation (AR), outcomes in adolescents and adults with sVSDs are not known.

METHODS

In this retrospective observational study, clinical data without surgery were obtained in 60 patients with sVSDs (group 1; mean age, 36 ± 13 years), 120 age- and defect size-matched patients with perimembranous ventricular septal defects (group 2), and 52 patients with sVSDs who underwent surgery (group 3; mean age, 32 ± 11 years).

RESULTS

Aortic sinus wall prolapse (38% vs 3%, P < .0001) and moderate to severe AR (7% vs 0%, P = .012) were more frequently observed in group 1 than in group 2. Five, three, and two patients in group 1 had surgery during follow-up because of rupture of the aneurysm of the sinus of Valsalva, endocarditis, and heart failure, respectively. Group 1 had a lower 12-year clinical event-free (surgery and endocarditis) rate (76 ± 9% vs 94 ± 4%, P = .031) but an equivalent overall survival rate (100% vs 94 ± 3%, P = .143) compared with group 2. Patients with maximal prolapsing aortic sinus wall length > 7 mm showed a higher frequency of aneurysm of the sinus of Valsalva rupture than those with no prolapse or maximal prolapsing length ≤ 7 mm (80% [four of five] vs 2% [one of 55], P < .001). The event-free and overall survival rates were comparable between groups 1 and 3, with equivalent 10-year AR progression-free survival rates (94 ± 5% vs 91 ± 5%, P = .301).

CONCLUSIONS

Aneurysm of the sinus of Valsalva rupture, rather than AR progression, was the main clinical event. Watchful monitoring of patients with high-risk echocardiographic features may be a rational option.

Demonstration of doubly committed juxta-arterial ventricular septal defect with aortic valve prolapse by cardiac computed tomography

A 24-year-old man presented to our hospital with symptoms of dyspnea and palpitation for 2 weeks. Cardiac CT showed not only a leaflet coaptation defect in the aortic valve but also a small ventricular septal defect (VSD) immediately beneath the prolapsed right coronary cusp. A shunt flow in the direction of the right ventricular outflow tract though the defect indicated the doubly committed juxta-arterial type of VSD. A doubly committed juxta-arterial VSD of 3 mm was confirmed and repaired via pulmonary arteriotomy.

Eisenmenger ventricular septal defect: classification, morphology, and indications for surgery

This study aimed to examine the definition and indications for surgery, to elucidate the morphologic substrate of aortic regurgitation, and to extrapolate the pathologic mechanisms of subpulmonary stenosis in Eisenmenger ventricular septal defect (EVSD). The study enrolled 160 patients. Preoperative respiratory symptoms and poor growth were present in 41 patients (26%), and 21 patients (13%) required mechanical ventilation. Perimembranous ventricular septal defect (pVSD) had been diagnosed previously for 136 of the patients (85%) at other institutions. Of the 160 patients, 51 (32%) had muscular posteroinferior rims. Aortic regurgitation was experienced by 36 patients (23%), found to be mild in 31 cases (19%) and moderate in 5 cases (3%). None of the patients had severe regurgitation. No aortic valvuloplasty was performed. The significant risk factors for aortic regurgitation were subpulmonary stenosis (p = 0.001) and a muscular posteroinferior rim (p = 0.000). Subpulmonary stenosis was seen in 57 patients (35%), found to be mild to moderate in 42 cases (26%) and severe in 15 cases (9%). Adequacy of the stenosis band was repaired through the tricuspid valve for 57 of these patients. The definition of EVSD should identify it as a subgroup different from pVSD, and it should be closed as soon as it is identified in developing countries. Aortic regurgitation occurs rarely, and aortic valvoplasty should be performed if it exceeds a moderate level. The subpulmonary stenosis can be repaired through the tricuspid valve.

Progression of aortic regurgitation after surgical repair of outlet-type ventricular septal defects

BACKGROUND

Progression of aortic regurgitation (AR) in repaired outlet ventricular septal defects (VSDs) remains unclear, especially for muscular outlet and perimembranous outlet VSDs. We tried to identify the risk factors for AR progression and aortic valve replacement (AVR) at long-term follow-up.

METHODS

Four hundred patients with complete follow-up after the repair of their outlet VSD between 1987 and 2002 were studied.

RESULTS

Juxta-arterial VSD, perimembranous outlet VSD, and muscular outlet VSD were noted in 190, 148, and 62 patients, respectively. There were 377 patients with none to mild AR (group I) and 23 with moderate to severe AR (group II) preoperatively. Aortic valve replacement was performed on 11 patients (all from group II), with 10 having received AVR concomitantly with VSD repair and 1 having received it 4 years later. Only severity of preoperative AR and older age (>15 years) at VSD repair were significant predictors of AVR. With a total follow-up of 2230 person-years, the 10-year freedom from AVR after VSD repair for group I was 100% and that for group II was 50.2%. In group I, AR progressed in 4 patients only (1.2%, 2 juxta-arterial and 2 perimembranous outlet) and aortic valvular (aortic valve prolapse or ruptured sinus Valsalva aneurysm) or subvalvular anomalies were present in all. The event-free (AR or AVR) survival rates among the 3 outlet-type VSDs however showed no difference.

CONCLUSIONS

Aortic regurgitation progression modes after surgical VSD repair were similar among the 3 outlet-type VSDs. Aortic valve replacement was rarely necessary for patients who were operated on when they were younger than 15 years. Aortic regurgitation of a less-than-moderate degree preoperatively rarely progressed after VSD repair.

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.