Grown-up Congenital Heart Disease (GUCH): Difference between revisions

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 When the ASD is closed percutaneously the short-term outcomes (less than one year) are excellent, with reported procedure success rates of 88 to 98%.
+=== Ventricular septal defect ===
+==== Case report ====
+==== Introduction ====
+The ventricular septal defect is the most common congenital heart defect in childhood (30%). Most patients have an isolated VSD, however a VSD also occurs in combination with other defects like Tetralogy of Fallot, which will be discussed elsewhere. About five percent of all patients with a VSD have a chromosomal abnormality, including trisomy 13, 18 and 21. Due to a high rate of spontaneous closure (50%) VSD is less seen in adulthood.
+There are three main anatomic components of the interventricular septum (figure 3); the septum of the atrioventricular canal (1), the muscular septum (2), the parietal band or distal conal septum (3). VSDs may occur at various locations in any of the three components. The location of the defect is not of particular interest when taking the characteristics of the intracardiac shunt in account. However it is important in terms of the frequency of involvement of the atrioventricular valves and the rate of spontaneous closure and additionally the relation to the AV pathway when considering surgical correction.
+==== Classification ====
+The VSD can be classified into four types, related to the anatomic components involved;
+:: Type 1 is the infundibular VSD, which results from a defect in the septum below the aortic and pulmonary valves. The loss of support to the adjacent septal leaflets of these valves causes cusp prolapse into the VSD leading to progressive aortic regurgitation, which is the hallmark of this defect.
+:: Type 2, the membranous VSD, is the most common type of VSD (around 80%) and results from a deficiency of the membranous septum. This defect borders the septal leaflet of the tricuspid valve and might also extend into the muscular septum when it is referred to as a perimembranous VSD.
+:: Type 3 are inlet VSDs, located beneath both mitral and tricuspid valves. Despite proximity to those valves, this type of defect is not associated with mitral or tricuspid regurgitation unless associated with atrioventricular canal defect. This typically large defect is often associated with Down syndrome.
+:: Muscular defects (type 4) are located within the trabecular septum and accounts for 5 – 20% of all VSDs. It is bordered only by muscle, away from the cardiac valves. Muscular defects can be small or large in size and consist of a single or multiple defects.
+==== 1.2.4 Pathophysiology ====
+The severity of the shunt across the VSD is determined by its size and the ratio of pulmonary to systemic vascular resistance. In small or restrictive VSDs the diameter of the defect is ≤25% of the aortic annulus diameter. These small defects cause small left to right shunts with no left ventricular overload or pulmonary hypertension.
+Moderate sized VSDs, measuring 25 – 75% of the aortic annulus diameter, result into mild volume overload of the pulmonary arteries, left atrium and left ventricle with no or only mild pulmonary hypertension.
+In large defects, defined as those with diameters equal or greater than 75% of the aortic annulus, there is no restriction of blood flow across the septum, leading to equal pressures in both right and left ventricle. The large left to right shunt initially only leads to excessive volume overload in the pulmonary arteries, left atrium and left ventricle. The chronic pressure and volume overload combined with the increase flow leads to irreversible changes of the pulmonary vasculature, which results in an increase in pulmonary vascular resistance. This increase in resistance leads to a reversal of the shunt through the VSD causing right to left shunt with cyanosis (Eisenmenger syndrome).
+==== 1.2.5 Evaluation ====
+Small defects are usually asymptomatic, however are fairly easy to detect during physical examination. There can be a palpable thrill accompanied by a holosystolic murmur grade 4-6. In some muscular defects the murmur is non holosystolic, due to the contraction and therby closure of the defect during systole. In moderate sized defects, with a large systemic to pulmonary flow of at least 1:2, a middiastolic rumble is audible due to the increased flow across the mitral valve. The pulmonary component of the second heart tone is loud. Only in a large VSD accompanied by the Eisenmenger syndrome and central cyanosis there is barely any shunt murmur audible. However there are murmurs audible caused by the pulmonary hypertension; an earlydiastolic murmur due to the pulmonary valve regurgitation and a holosystolic murmur due to the tricuspid valve regurgitation.
+Defects with large shunts that cause symptoms like decreased exercise tolerance and dyspnoe are usually detected and closed early in childhood.
+The ECG and chest X-ray of a patient with a small VSD are usually normal, but can show signs of left atrial and left ventricle overload in moderate sized defects.
+With echocardiography the localisation, size and hemodynamic influence of the VSD can be investigated. Dilatation of the left atrium and left ventricle might be present and the pressures in the pulmonary artery can be estimated by means of the tricuspid regurgitation. Invasive measurement by means of catheterization is only indicated when there is doubt about the shunt size and the pulmonary vascular resistance.
+==== 1.2.6 Treatment ====
+Treatment and prognosis of a VSD depends on the size en localisation of the defect, the pulmonary vascular resistance and possible concomitant defects. Spontaneous closure occurs mainly in small defects, of which 75 percent closes before age 10. In patients with a small defect no pulmonary hypertension develops, however there is an increased risk of endocarditis.
+In patients with significant shunts studies have shown that surgical closure reduces pulmonary artery pressure and improves long-term survival. Therefore, repair of VSD should be considered in all adult patients who are symptomatic or have signs of left ventricular volume overload.
+Medical treatment is reserved for (1) asymptomatic patients without evidence of left ventricular volume overload and (2) patients with symptoms and/or left ventricular volume overload who are not candidates for repair such as those with large defects and Eisenmenger syndrome.
+Medical treatment is reserved for (1) asymptomatic patients without evidence of left ventricular volume overload and (2) patients with symptoms and/or left ventricular volume overload who are not candidates for repair such as those with large defects and Eisenmenger syndrome.
+Medical treatment is reserved for (1) asymptomatic patients without evidence of left ventricular volume overload and (2) patients with symptoms and/or left ventricular volume overload who are not candidates for repair such as those with large defects and Eisenmenger syndrome.
+* Closure of a VSD is indicated when there is a Qp/Qs ≥2 and clinical evidence of LV volume overload.
+* Closure of a VSD is indicated when the patient has a history of infective endocarditis.
+* Closure of a VSD is reasonable when there is net left to right shunting with a Qp/Qs ≥1.5 with pulmonary artery pressure less than two thirds of systemic pressure and PVR is less than two thirds of systemic vascular resistance.
+* Closure of a VSD is reasonable when there is net left to right shunting with a Qp/Qs ≥1.5 in the presence of LV systolic or diastolic dysfunction or failure.
+Indications for surgical closure of VSD in infants and young children may include:
+* Infants <6 months (<3 months for those with trisomy 21) who have uncontrolled heart failure despite maximal medical and dietary interventions or who have pulmonary hypertension.
+* Children with a persistent significant shunt (Qp:Qs >2:1), should undergo surgical repair even in the absence of elevated PA pressures.
+* Subpulmonic and membranous defects, regardless of size, with aortic regurgitation should be surgically corrected before the aortic valve is permanently damaged. The decision to close small defects with aortic valve prolapse without aortic regurgitation is controversial.
+Closure of a VSD is not recommended in patients with severe irreversible pulmonary artery hypertension.
+Transcatheter device VSD closure is a treatment option for isolated uncomplicated muscular VSDs, and for certain membranous VSDs, in selected patients with suitable anatomy. Appropriate anatomy for transcatheter closure includes a VSD location remote from the tricuspid and aortic valves with an adequate rim. Successful transcatheter closure has been accomplished in the presence of multiple muscular or membranous fenestrations.
+The technical success rate of transcatheter closure of selected muscular and membranous VSDs is high (93-100%) and the mortality rate is low (0 – 2.7%).
+==== Outcome ====
+The long-term outcome for children who undergo surgical closure of VSD in childhood is generally excellent. Early surgical repair results in near normal long-term growth in the vast majority of patients. Most survivors are asymptomatic and lead normal lives.
+Adults with repaired VSD without residua have excellent outcomes and normal survival, with a 25year survival of 83%. However, long-term survival is less favorable when repair is done at older age or in presence of pulmonary hypertension. Although the prognosis after surgical repair of uncomplicated VSD is excellent in the majority of patients, long-term residua and sequelae are not uncommon including conduction disease, cardiac arrhythmias, residual VSD, endocarditis, tricuspid regurgitation, ventricular dysfunction, pulmonary hypertension, and aortic regurgitation.
+Development of complete atrioventricular block is the most significant of the transcatheter procedural complications. Approximately 6% of patients who underwent transcatheter closure of membranous defects, developed complete heart block necessitating pacemaker implantation. Real-time three-dimensional transesophageal echocardiography has been increasingly used to guide such procedures. Given the lack of data on long-term outcomes following catheter closure of VSD in adults, patients should be followed every one to two years at an adult congenital heart disease center.