Q: My 25 years old son is having congenital sub pulmonic outlet ventricular septal defect (VSD) measuring 3 mm with blood pressure gradient of 150 mm/Hg. It is asymptomatic. He is also having mild prolapse and mild regurgitation of the aortic valve. Does he need VSD closure? Can it be done through device closures? I came to know that during surgery, it may damage the AV node of the heart or may injure the nearby valves causing the onset of total heart block and sudden death even many years after the surgery and leaking of valves, respectively. As such, he is already having mild prolapse and mild leaking of aortic valve; can this be managed non-surgically? Considering my son's condition, are the risks of surgery more than that of the unclosed VSD? Should we go ahead with the surgery or not?

A:

• Any VSD should be closed. Even though your son is asymptomatic, he has started developing prolapse and mild leakage of the aortic valve, which may progress over a period of time, as also he is a candidate for complications like infective endocarditis (infection of heart).
• VSDs can be closed by a device, but then there are certain pre-requisites for the device closure. Generally outlet VSDs are not good candidates for device closure but this decision can only be taken by an interventional cardiologist after he views and profiles your VSD on echocardiography, as lot of technical factors like the quality of rim of the defect, closeness to vital structures and to pulmonary and aortic valve have to be taken into account before deciding on device or surgical closure.
• Electrical conduction system can be injured during surgery but that usually occurs in a kind of VSD called perimembranous VSD as the electrical conduction bundle lies very close to the lower edge of the defect. However, your son has got subpulmonic outlet VSD and the danger of damage to the conduction bundle is very little, if any, in this surgery.
• VSD certainly can be managed without surgery as long as you are ready to accept the risks involved of not operating. As the VSD is relatively small, it is unlikely that it will give rise to pulmonary arterial hypertension (High pressure of the lungs). However, it can produce infection on the inner lining of the heart and as it is producing prolapse of the aortic valve, it may lead to increased and continued leak of the valve.
• The risk of closure of VSD now days is around 1% and therefore, I would strongly advise that the VSD should be closed. However, I would like to clarify that it is always best to have direct access to a patient before these comments are made and therefore, though I have made certain general statements, whether they are applicable to your son, can only be verified by your cardiologist, who has access to direct clinical examination and to other investigations.