SURGICAL-MANAGEMENT OF VENTRICULAR SEPTAL-DEFECT WITH AORTIC-VALVE PROLAPSE - CLINICAL CONSIDERATIONS AND RESULTS

Aortic valve prolapse is found in over 5% of children with ventricular septal defect (VSD). Although this association occurs mostly with dou bly committed subarterial VSDs, in this study the predominant type of VSD was perimembranous. In order to determine the need and timing for surgery and whether the anatomical features of septal defect may influ ence clinical management and outcome in this lesion, we reviewed our e xperience with 28 consecutive patients, operated on for VSD with prola psed aortic valve cusp, with or without aortic regurgitation. Twenty-t wo patients had a perimembranous VSD and six had doubly committed VSD. Aortic regurgitation was trivial or absent in nine patients, mild in ten and moderate to severe in nine. Associated cardiac anomalies were present in 18 patients, all having perimembranous VSD, and included ri ght ventricular outflow tract (RVOT) obstruction (n = 6), discrete sub aortic membrane (n = 4) or both (n = 8). None of these patients had mo re than moderate aortic regurgitation. The patients underwent surgical closure of the septal defect between the ages of 1.5 and 34 years of age (median = 7). Sixteen patients having mild or trivial aortic regur gitation underwent closure of the VSD only, and 12 patients underwent VSD closure with aortic valvuloplasty. Valvuloplasty was required more often in doubly committed VSDs (66%) and in the perimembranous type w ithout associated anomalies (100%), and significantly less often in th e presence of RVOT obstruction, subaortic membrane or both (22%). At f ollow-up (up to 5 years, mean 18 months), the grade of aortic regurgit ation was unchanged in 11 and decreased in 5 patients undergoing closu re of the VSD only. Of the 12 patients undergoing valvuloplasty, the g rade of aortic regurgitation decreased in 9 (from moderate or severe t o mild or absent), and remained unchanged in 3. The anatomic type of V SD was not related to surgical outcome. Aortic valve prolapse in patie nts with perimembranous VSD and associated RVOT obstruction, discrete subaortic membrane or both seems to be less severe and aortic regurgit ation progression seems slower than in patients with doubly committed VSD or perimembranous VSD with no other anomalies. In this subgroup, a ortic prolapse may not constitute an indication for early surgical int ervention.