eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Ventricular Septal Defect, Perimembranous: Follow-up

Author: Michael D Taylor, MD, PhD, Assistant Professor, Departments of Pediatrics (Division of Cardiology) and Radiology, Baylor College of Medicine, Texas Children's Hospital
Coauthor(s): Benjamin W Eidem, MD, FACC, FASE, FAAP, Associate Professor, Divisions of Pediatric Cardiology and Cardiovascular Diseases, Department of Pediatrics, Mayo Clinic College of Medicine
Contributor Information and Disclosures

Updated: Nov 25, 2008

Follow-up

Further Inpatient Care

  • Routine inpatient monitoring of infants and children with small perimembranous ventricular septal defects (VSDs) is not necessary.
  • Mild-to-moderate congestive heart failure (CHF) secondary to large left-to-right shunting caused by a VSD is managed on an outpatient basis.
  • Severe CHF requiring hospitalization indicates the need for early intervention for VSD closure.

Further Outpatient Care

  • Small perimembranous VSDs have a 50% spontaneous closure rate. Perform serial follow-up care until the VSD closes.
  • For routine perimembranous VSDs, antibiotics for the prevention of bacterial endocarditis are no longer recommended by the American Heart Association.7  A modest risk of endocarditis is still observed; thus, the importance of vigilant oral hygiene should be reinforced. For more information, see Endocarditis, Bacterial.
  • Perform surgical closure of any size of VSD with the development of progressive aortic valve regurgitation.
  • Manage moderately-sized VSDs on an outpatient basis by monitoring for evidence of a reduction in size or a spontaneous closure. Assess patient growth and evaluate the need for elective surgical closure.
  • Manage patients with large VSDs and no CHF on an outpatient basis.
  • Infants who do not respond to medical therapy (eg, poor weight gain) are candidates for surgical closure.

Inpatient & Outpatient Medications

  • Diuretics, such as furosemide and spironolactone, decrease volume overload in patients with large VSDs.
  • Captopril or enalapril may be used to reduce afterload.
  • In some centers, digoxin is used as an inotrope to augment ventricular contractility in patients with a large VSD and evidence of CHF.

Transfer

  • Patients with large or multiple VSDs may be transferred to a tertiary care center for further diagnostic evaluation or surgical intervention.

Complications

  • CHF
  • Bacterial endocarditis
  • Eisenmenger syndrome
  • Aortic insufficiency
  • Subaortic stenosis
  • Double-chambered right ventricle

Prognosis

  • Children with small-to-moderate sized VSDs have an excellent prognosis.
  • Infants and children with large VSDs have a good prognosis.
  • Optimal medical management, with appropriate timing of surgical intervention, has the best outcome.

Patient Education

  • Advise patient and/or parents regarding the risks of bacterial endocarditis indications and the importance of oral hygiene. Educate them concerning signs and symptoms of CHF.
  • For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education articles Congestive Heart Failure and Ventricular Septal Defect.

Miscellaneous

Medicolegal Pitfalls

  • Failure to surgically close the ventricular septal defect (VSD) prior to the development of pulmonary vascular obstructive disease
  • Failure to detect associated heart lesions or sequelae prior to or following surgery (aortic insufficiency, subaortic stenosis)
  • Failure to counsel parents and patients regarding the risk of bacterial endocarditis
  • Failure to detect associated lesions
  • Failure to detect chronic left ventricular dilatation
 


More on Ventricular Septal Defect, Perimembranous

Overview: Ventricular Septal Defect, Perimembranous
Differential Diagnoses & Workup: Ventricular Septal Defect, Perimembranous
Treatment & Medication: Ventricular Septal Defect, Perimembranous
Follow-up: Ventricular Septal Defect, Perimembranous
References
[ CLOSE WINDOW ]

References

  1. Williams LJ, Correa A, Rasmussen S. Maternal lifestyle factors and risk for ventricular septal defects. Birth Defects Res A Clin Mol Teratol. Feb 2004;70(2):59-64. [Medline].

  2. Oberlander TF, Warburton W, Misri S, Riggs W, Aghajanian J, Hertzman C. Major congenital malformations following prenatal exposure to serotonin reuptake inhibitors and benzodiazepines using population-based health data. Birth Defects Res B Dev Reprod Toxicol. Feb 2008;83(1):68-76. [Medline].

  3. Chen FL, Hsiung MC, Nanda N, Hsieh KS, Chou MC. Real time three-dimensional echocardiography in assessing ventricular septal defects: an echocardiographic-surgical correlative study. Echocardiography. Aug 2006;23(7):562-8. [Medline].

  4. Fu YC, Bass J, Amin Z, et al. Transcatheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: results of the U.S. phase I trial. J Am Coll Cardiol. Jan 17 2006;47(2):319-25. [Medline].

  5. Thanopoulos BD. Catheter closure of perimembranous/membranous ventricular septal defects using the Amplatzer occluder device. Pediatr Cardiol. Jul-Aug 2005;26(4):311-4. [Medline].

  6. Fischer G, Apostolopoulou SC, Rammos S, Schneider MB, Bjornstad PG, Kramer HH. The Amplatzer Membranous VSD Occluder and the vulnerability of the atrioventricular conduction system. Cardiol Young. Oct 2007;17(5):499-504. [Medline].

  7. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  8. Arciniegas E, Farooki ZQ, Hakimi M, et al. Surgical closure of ventricular septal defect during the first twelve months of life. J Thorac Cardiovasc Surg. Dec 1980;80(6):921-8. [Medline].

  9. Chessa M, Butera G, Negura D, et al. Transcatheter closure of congenital ventricular septal defects in adult: Mid-term results and complications. Int J Cardiol. Jan 28 2008;[Medline].

  10. Dammann JF Jr, Thompson WM Jr, Sosa O. Anatomy, physiology and natural history of ventricular septal defects. Am J Cardiol. 1960;5:136-66.

  11. Haworth SG. Pulmonary vascular disease in ventricular septal defect: structural and functional correlations in lung biopsies from 85 patients, with outcome of intracardiac repair. J Pathol. Jul 1987;152(3):157-68. [Medline].

  12. Hoffman JI, Rudolph AM. The natural history of ventricular septal defects in infancy. Am J Cardiol. Nov 1965;16(5):634-53. [Medline].

  13. Houston AB, Lim MK, Doig WB, et al. Doppler assessment of the interventricular pressure drop in patients with ventricular septal defects. Br Heart J. Jul 1988;60(1):50-6. [Medline].

  14. Kidd L, Driscoll DJ, Gersony WM, et al. Second natural history study of congenital heart defects. Results of treatment of patients with ventricular septal defects. Circulation. Feb 1993;87(2 Suppl):I38-51. [Medline].

  15. McMahon CJ, Said HG, Clapp SK. Interrupted aortic arch type B in trisomy 21: repair with carotid artery interposition. Pediatr Cardiol. Jan-Feb 2003;24(1):40-2. [Medline].

  16. Moller JH, Patton C, Varco RL, et al. Late results (30 to 35 years) after operative closure of isolated ventricular septal defect from 1954 to 1960. Am J Cardiol. Dec 1 1991;68(15):1491-7. [Medline].

  17. Nadas AS, Fyler DC. Ventricular septal defects. In: Nadas's Pediatric Cardiology. Philadelphia, PA: Hanley & Belfus Inc; 1992:435-57.

  18. Pieroni DR, Nishimura RA, Bierman FZ, et al. Second natural history study of congenital heart defects. Ventricular septal defect: echocardiography. Circulation. Feb 1993;87(2 Suppl):I80-8. [Medline].

  19. Rudolph AM. The effects of postnatal circulatory adjustments in congenital heart disease. Pediatrics. Nov 1965;36(5):763-72. [Medline].

  20. Sharif DS, Huhta JC, Marantz P, et al. Two-dimensional echocardiographic determination of ventricular septal defect size: correlation with autopsy. Am Heart J. Jun 1989;117(6):1333-6. [Medline].

  21. Soto B, Becker AE, Moulaert AJ, et al. Classification of ventricular septal defects. Br Heart J. Mar 1980;43(3):332-43. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

ventricular septal defect, VSD, perimembranous, membranous ventricular septal defect, ventricular septum, right ventricular outflow obstruction, congestive heart failure, CHF, cardiac lesion, atrial septal defect, ASD, patent ductus arteriosus, prematurity, pulmonary valve stenosis, pulmonary venous obstruction, persistent elevation of pulmonary vascular resistance, mitral stenosis, Eisenmenger syndrome, cardiomegaly

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Michael D Taylor, MD, PhD, Assistant Professor, Departments of Pediatrics (Division of Cardiology) and Radiology, Baylor College of Medicine, Texas Children's Hospital
Michael D Taylor, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Society for Cardiovascular Magnetic Resonance
Disclosure: Nothing to disclose.

Coauthor(s)

Benjamin W Eidem, MD, FACC, FASE, FAAP, Associate Professor, Divisions of Pediatric Cardiology and Cardiovascular Diseases, Department of Pediatrics, Mayo Clinic College of Medicine
Benjamin W Eidem, MD, FACC, FASE, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Society of Echocardiography, Society for Pediatric Research, and Society of Pediatric Echocardiography
Disclosure: Nothing to disclose.

Medical Editor

Juan Carlos Alejos, MD, Associate Clinical Professor, Department of Pediatrics, Division of Cardiology, University of California at Los Angeles
Juan Carlos Alejos, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Medical Association, and International Society for Heart and Lung Transplantation
Disclosure: Actelion Honoraria Speaking and teaching

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Hugh D Allen, MD, Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine
Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College
Gilbert Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.