RESTRICTIVE VENTRICULAR SEPTAL-DEFECT - HOW SMALL IS TOO SMALL TO CLOSE

Historically, indications for ventricular septal defect closure have i ncluded congestive heart failure, pulmonary hypertension, aortic insuf ficiency with or without aortic valve prolapse, and prior bacterial en docarditis. However, controversy exists as to how the lifetime risk of an isolated, nonoperated restrictive ventricular septal defect compar es with the risk of surgical closure in an asymptomatic child. Between 1980 and 1991, cardiac catheterization and elective ventricular septa l defect closure (age > 1 year, pulmonary to systemic flow ratio < 2.0 ) were performed in 141 patients aged 1 to 23 years (mean age, 6.1 +/- 4.7 years). Mean systolic pulmonary artery pressure was 26.9 +/- 13.0 mm Hg, and mean pulmonary to systemic flow ratio was 1.6 +/- 0.3. Aor tic valve prolapse was present in 63 patients (45%), aortic insufficie ncy was present in 25 (18%), and 5 (3.5%) had prior bacterial endocard itis. There were no early or late deaths or major morbidity. No patien t required a ventriculotomy to accomplish ventricular septal defect cl osure. Mean postoperative intensive care unit stay was 1.3 +/- 0.9 day s, and mean hospital stay was 5.5 +/- 1.9 days. There were no instance s of permanent complete atrioventricular dissociation, reoperations fo r bleeding, postoperative wound infections, or reoperations for residu al or recurrent ventricular septal defect. These improved results just ify a reevaluation of historic indications for ventricular septal defe ct closure. Surgical closure of a restrictive ventricular septal defec t removes the socioeconomic stigma associated with living with an unco rrected cardiac defect, and the surgical risk as defined by this exper ience when compared with known natural history studies is less than th e lifetime risks of development of bacterial endocarditis or progressi ve aortic valve prolapse leading to aortic insufficiency.