Outflow Ventricular Septal Defect With Aortic Regurgitation: Optimal Timing of Surgery?

Outcomes of aortic valve repair with ventricular septal defect closure: An elusive task

“…There is another recent study from India involving patients with outflow VSDs and AR; interestingly, 48% of the patients had a perimembranous VSD 4 . In this report, it was shown that in patients with moderate or severe AR preoperatively a perimembranous VSD was found to be associated with worsening of AR during a mean follow‐up period of 6.3 years, whereas a juxtaarterial VSD was not 4 . These two studies from India suggest that patients with a hemodynamically insignificant, unrepaired, perimembranous VSD need long‐lasting follow‐up to detect the development of AR 1,4 …”

“…They found that only 1.5% of the patients needed surgery for aortic valve prolapse or AR, concluding that aortic valve involvement in patients with a perimembranous VSD is rare and that frequent follow‐up may be unnecessary for the majority although their follow‐up was not long 3 . There is another recent study from India involving patients with outflow VSDs and AR; interestingly, 48% of the patients had a perimembranous VSD 4 . In this report, it was shown that in patients with moderate or severe AR preoperatively a perimembranous VSD was found to be associated with worsening of AR during a mean follow‐up period of 6.3 years, whereas a juxtaarterial VSD was not 4 .…”

“…1 This is not a new finding. 4,6 For example, Cheung et al 6 analyzed 135 patients who underwent subarterial VSD closure and found that in a subset of 17 patients who had an additional aortic valve repair due to AR ≥ moderate, freedom from residual AR ≥ moderate at 10 years was 43%. The uniqueness of the findings by Kaskar et al 1 consists in the larger number of patients who underwent aortic valve repair compared in their study with previous reports.…”

“…These poor long‐term results following aortic valve repair suggest that the surgical techniques to address leaflet prolapse in the setting of VSD and AR are only partially effective in terms of long‐term durability. In most of the previous literature including this article from Kaskar et al, 1 the technique reported by Trusler et al 7 has been widely adopted 1,4,6 . In the adult cardiac surgery world where aortic valve repair has been gaining momentum, central leaflet plication has become a popular technique to correct leaflet prolapse whereas the Trusler technique is rarely used 8 .…”

“…4 These two studies from India suggest that patients with a hemodynamically insignificant, unrepaired, perimembranous VSD need long-lasting follow-up to detect the development of AR. 1,4 Second, the patients' pathophysiological background in the cohort reported in this article might have been heterogeneous, including "atypical" patients with VSD and AR. As a general rule, VSD patients who need surgery for aortic valve disease are older with more restrictive left-to-right shunting and normal pulmonary artery pressure than VSD patients who need surgery for congestive heart failure.…”