When should we close ventricular septal defects?

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With the advent of catheter-based cardiac intervention, we are now capable of doing things that used to require open heart surgery in a less invasive manner. This progress has also allowed a thought process of potentially closing smaller and smaller ventricular septal defects (VSD). Important questions emerge about the appropriate indications for closure of VSD. In this issue of The Journal, Kleinman et al address these issues by reporting on a study of the natural history of unoperated patients with a moderate to large VSD and with left ventricular (LV) dilation. They found that most patients with pressure-restrictive VSDs, with moderate to large severe LV dilation, without heart failure, failure to thrive, or pulmonary hypertension will spontaneously decrease LV dilation over time without intervention.

In an accompanying editorial, Beekman puts these findings in clinical perspective. He emphasizes that just because we can close VSDs without surgery, does not mean we should close them. He indicates that studies like that of Kleinman et al help to provide the evidence base we can use to make rational decisions about when to intervene. In most asymptomatic children with pressure restricted VSDs, even when they are relatively large, trans-catheter intervention is not needed to result in a favorable outcome.