Subspecialty surveillance of long-term course of small and moderate muscular ventricular septal defect: heterogenous practices, low yield

Abstract

BackgroundNo expert consensus guides practice for intensity of ongoing pediatric cardiology surveillance of hemodynamically insignificant small and moderate muscular ventricular septal defect (mVSD). Therefore, despite the well-established benign natural history of mVSD, there is potential for widely divergent follow up practices. The purpose of this investigation was to evaluate (1) variations in follow up of mVSD within an academic children’s hospital based pediatric cardiology practice, and (2) the frequency of active medical or surgical management resulting from follow up of mVSD.MethodsWe retrospectively reviewed records of 600 patients with isolated mVSD echocardiographically diagnosed between 2006 and 2012. Large mVSD were excluded (n = 4). Patient age, gender, echocardiographic findings, provider, recommendations for follow up, and medical and surgical management were tabulated at initial and follow up visits. Independent associations with follow up recommendations were sought using multivariate analysis.ResultsInitial echocardiography showed small single mVSD in 509 (85%), multiple small mVSD in 60 (10%), and small-to-moderate or moderate single mVSD in 31 (5%). The mean age at diagnosis was 15.9 months (0–18.5 years) and 25.7 months (0–18.5 years) at last follow up. There was slight female predominance (56.3%). Fourteen pediatric cardiology providers recommended 316 follow up visits, 259 of which were actually accomplished. There were 37 other unplanned follow up visits. No medical or surgical management changes were associated with any of the follow up visits. The proportion of patients for whom follow up was advised varied among providers from 11 to 100%. Independent associations with recommendation for follow up were limited to the identity and clinical volume of the provider, age of the patient, and the presence of multiple, small-to-moderate, or moderate mVSD.ConclusionsIn this large series of moderate or smaller mVSD, pediatric cardiology follow up was commonly recommended but resulted in no active medical or surgical management. Major provider based inconsistency in intensity of follow up of mVSD was identified, but is difficult to justify.

Incidence and natural history of neonatal isolated ventricular septal defects: Do we know everything? A 6-year single-center Italian experience follow-up

“…In our experience, among muscular VSD at 2‐year follow‐up the probability of spontaneous closure was higher for central type compared to apical and marginal type ( P = .003 and P = .006, respectively; Table ), whereas at 6‐year follow‐up no more statistical differences were present ( P = .6). A reduction of the probability of spontaneous closure after the second year of life has been recently reported by Xu et al, although the possibility of closure until adolescence and even in adult life are described …”

“…In our institutional adult IE database, however, VSDs accounted for 9.7% of 205 consecutive cases (unpublished data). Another unresolved issue is the follow‐up protocol; in fact, high volume providers believe that, in case of small defects, the cost/benefit ratio for a follow‐up may not be worth the effort . Otherwise, other authors have suggested that, irrespective of dimensions, VSDs persisting in adulthood should be followed since they may lead to severe complications (ie, IE, aortic regurgitation, occurrence of arrhythmias) .…”

“…Questions occur such as: how often does a follow‐up investigation have to be performed or when can patients be discharged? Recent surveys have revealed a great discordance among pediatric cardiologists (even operating within the same country) on the follow‐up frequency of small to moderate VSDs, and no guidelines/experts consensus opinions are currently available . Thus, VSDs are often simple defects with a clinical dilemma.…”

The natural history of fetal diagnosed isolated ventricular septal defect

“…The natural closure rate of isolated VSD in this study is slightly higher than that of Jin et al 10 but slightly lower than some other studies. 1,11 The reason why natural closure rate of isolated VSD is different for each study will be largely affected by the distribution of target patients. However, more study will be needed to find more details.…”

Persistent Fever in a Teenager

“…15 However, since up to 75% of small isolated VSDs close spontaneously by age 10 years and neither surgical nor medical intervention is recommended for an asymptomatic pediatric patient, most of them are already discharged from cardiology follow-ups around the adolescent years, regardless whether or not the small defect has closed. 14,16 Hence, they never reach an adult cardiologist. It is unclear whether a long-term follow-up on the pediatric patients with persistent small opened VSDs can decrease the risk of IE and other complications.…”