Recent advances in managing septal defects: ventricular septal defects and atrioventricular septal defects

Abstract

This review discusses the management of ventricular septal defects (VSDs) and atrioventricular septal defects (AVSDs). There are several types of VSDs: perimembranous, supracristal, atrioventricular septal, and muscular. The indications for closure are moderate to large VSDs with enlarged left atrium and left ventricle or elevated pulmonary artery pressure (or both) and a pulmonary-to-systemic flow ratio greater than 2:1. Surgical closure is recommended for large perimembranous VSDs, supracristal VSDs, and VSDs with aortic valve prolapse. Large muscular VSDs may be closed by percutaneous techniques. A large number of devices have been used in the past for VSD occlusion, but currently Amplatzer Muscular VSD Occluder is the only device approved by the US Food and Drug Administration for clinical use. A hybrid approach may be used for large muscular VSDs in small babies. Timely intervention to prevent pulmonary vascular obstructive disease (PVOD) is germane in the management of these babies. There are several types of AVSDs: partial, transitional, intermediate, and complete. Complete AVSDs are also classified as balanced and unbalanced. All intermediate and complete balanced AVSDs require surgical correction, and early repair is needed to prevent the onset of PVOD. Surgical correction with closure of atrial septal defect and VSD, along with repair and reconstruction of atrioventricular valves, is recommended. Palliative pulmonary artery banding may be considered in babies weighing less than 5 kg and those with significant co-morbidities. The management of unbalanced AVSDs is more complex, and staged single-ventricle palliation is the common management strategy. However, recent data suggest that achieving two-ventricle repair may be a better option in patients with suitable anatomy, particularly in patients in whom outcomes of single-ventricle palliation are less than optimal. The majority of treatment modes in the management of VSDs and AVSDs are safe and effective and prevent the development of PVOD and cardiac dysfunction.

Clinical signs and symptoms of toxic serum digoxin levels in neonates

“…Moderate to large ventricular septal defects with signs of CHF require treatment in the neonatal period. 10 Although most children with isolated atrial septal defects are free of symptoms and require no medication, neonates with significant a large left-to-right shunt causing heart failure symptoms require treatment, although this is rare. Diuretics, afterload reducing agents, and digoxin have been used to treat CHF.…”

“…Diuretics, afterload reducing agents, and digoxin have been used to treat CHF. 10 Digoxin toxicity occurs more commonly in neonates and infants. 11 Toxic digoxin levels can cause extracardiac and life-threatening cardiac effects.…”

Timing of cardiac surgery and other intervention among children with congenital heart disease: A review article

“…In Partial AVSD, surgery at about 2-3 years of age is advocated, however, associated signi icant AV regurgitation may necessitate early surgical intervention. Pulmonary artery banding should be done if risk of cardiopulmonary bypass is considered high [13][14][15][16][17]. Regrettably, in the developing country and sub-Saharan Africa, children with atrio-septal defects were maintained on anti-failure regimen with regular follow up until surgical intervention is possible.…”

“…Generally, in symptomatic infants with VSD, pulmonary vascular disease is usually prevented when surgery is performed within the 1st year of life except if there is evidence of shunt becoming restrictive [14][15][16][17][18][19][20][21][22][23][24]. For large VSD with uncontrolled congestive heart failure, closure should be done as soon as possible while in large VSD with severe pulmonary artery hypertension, closure should be done at 3-6 months of age.…”

“…For moderate VSD where pulmonary artery systolic pressure is 50%-66% of systemic pressure, closure should be at 1-2 years of age or earlier if one episode of life threatening lower respiratory tract infection or failure to thrive ensues [18][19][20][21][22][23][24]. In the case of small sized VSD, with normal pulmonary artery pressure and left to right shunt >1.5:1, it is important to institute closure by 2-4 years [14][15][16][17][18][19]. Small outlet VSD (<3mm) without aortic valve prolapse should be on 1-2 yearly follow up to look for development of aortic valve prolapse.…”