Long-Term Outcomes After Surgical VSD Closure | Journal Scan

Study Questions:

What are the long-term (>30-year) outcomes after surgical ventricular septal defect (VSD) closure?

Methods:

Longitudinal follow-up of patients undergoing childhood surgical closure of VSD between 1968 and 1980 was performed. Patients were re-examined every 10 years, and in 2012, eligible patients were invited to participate in a comprehensive evaluation including examination, electrocardiography, Holter monitoring, echocardiography, bicycle ergometry, N-terminal pro–B-type natriuretic peptide measurement, and assessment of perceived health status with the Short Form-36 instrument.

Results:

A total of 174 patients constituted the original cohort. There were 17 early postoperative deaths. A total of 107 patients participated in the 1990 follow-up study, 95 in the 2001 follow-up study, and 91 in the current study. Cumulative survival for those surviving the 30-day postoperative period was 86% at 40 years. Causes of mortality included heart failure, endocarditis, post-valvular surgery, pulmonary hypertension, and noncardiac causes. Symptomatic arrhythmias occurred in 13%. Prevalence of right ventricle systolic dysfunction increased from 1% in 2001, to 17% in 2012 (p = 0.001). Left ventricular systolic function was impaired, but stable in 21%. Mild or greater aortic regurgitation was present in 21% of patients in the most recent assessment, and mean exercise capacity decreased, with 48% of patients having maximal workload <85% predicted. NT-proBNP was elevated (>14 pmol/L) in 38%. Patients’ assessment of their health status was significantly higher than a reference population.

Conclusions:

The authors concluded that survival up to 40 years after successful surgical VSD closure is good, slightly lower than the general Dutch population, but that morbidity is not insignificant.

Perspective:

This study demonstrates quite good long-term outcomes after surgical VSD closure. Mortality is slightly lower than that reported for the general population, but long-term issues can develop, including atrial arrhythmias, ventricular dysfunction, and aortic regurgitation. The study was limited by attrition and lack of patient participation, with 68% of survivors participating in any fashion, and 57% of survivors undergoing echocardiography. The late increase in right ventricular dysfunction as well as the apparent increase in aortic regurgitation deserves further study. Interestingly, perceived health status of survivors was higher than that reported for the general population, a phenomenon that has been seen in some (but not all) studies of patients with congenital heart disease. The development of late complications after surgical closure supports the practice of continued, intermittent follow-up for adults following surgical closure of VSD in childhood.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Imaging, CHD & Pediatrics and Quality Improvement, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Pulmonary Hypertension, Echocardiography/Ultrasound

Keywords: Aortic Valve Insufficiency, Arrhythmias, Cardiac, Echocardiography, Electrocardiography, Electrocardiography, Ambulatory, Endocarditis, Ergometry, Follow-Up Studies, Health Status, Heart Defects, Congenital, Heart Failure, Heart Septal Defects, Ventricular, Heart Ventricles, Hypertension, Pulmonary, Natriuretic Peptide, Brain, Peptide Fragments, Prevalence, Survivors, Ventricular Dysfunction, Right, Ventricular Function, Left, Workload


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