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

Percutaneous Device Closure of Perimembranous Ventricular Septal Defects Associated with Aortic Valve Prolapse and Aortic Regurgitation

The progression of aortic regurgitation (AR) in perimembranous ventricular septal defects (pVSD) remains uncertain; research indicates that the accompanying AR tends to worsen over time. There is controversy surrounding the percutaneous closure of defects in patients with pVSD associated with aortic valve prolapse (AVP) and AR. Our research focused on transcatheter closure for pVSD accompanied by AVP, AR, and septal aneurysm, with the aim of addressing challenges through device placement in aneurysmal tissue to eliminate the Venturi effect. We studied 44 patients with AVP, AR, and septal aneurysm who underwent transcatheter device closure. The mean age and weight were 10.5 ± 4.0 years and 36.0 ± 15.1 kg, respectively. Transcatheter closure was attempted in 44 patients. One case (2.3%) was referred to surgery, while the procedure was successfully completed in 43 out of 44 patients (97.7%). Early complications were minimal. Embolization of the device to the pulmonary artery was observed in one patient; upon re-evaluation, significant aneurysm tissue damage was detected, leading to a referral for surgery. Additionally, three patients (6.9%) developed permanent incomplete right bundle branch block (iRBBB). The median follow-up time was 43 months. During the follow-up period, AR progressed in only 1(2.3%) patient, while AR in 7(16.3%) patients regressed markedly. Follow-up assessments demonstrated high rates of complete occlusion; the rates at immediate, 24 h, 6 months, and 1 year were assessed as 72, 83.7, 93, and 95.3%, respectively. Transcatheter device closure of pVSD offers a minimally invasive, safe, effective, and alternative treatment option for patients with pVSD associated with AVP and AR.

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.