Spontaneous Functional Closing of Ventricular Septal Defects

Abstract

The development of 790 untreated patients affected by ventricular septal defect (VSD) has been the object of a 25-year study. Of these patients, 72% had had at least one catheterization; 13% had several. The mean observation interval is six years, and the average age at the latest data is 19.5 years. This study covers 4,717 patient-years. Of the 499 cases with several clinical examinations, 71% remained stable. In 21%, changes suggesting some level of closure developed; in 7%, infundibular stenosis began to evolve and in 1% pulmonary vascular disease began to appear or became accentuated. These different rates are studied and discussed in relation to patients’ age, VSD type, and various follow-up characteristics. Spontaneous closure was observed; however, this study does not permit any evaluation of its absolute frequency, as one would have had to follow an entire population from birth to death. Nor could a true appraisal of the closure’s frequency with age be made from our data; the time elapsed between two successive examinations varied widely and in some the interval was very long and prevented any reasonable estimate of the age when spontaneous closure took place. The age characteristics of patients with spontaneous closure were looked at. The age at which the defect was last seen open was evaluated. This analysis will underestimate the age of closure, but may help in determining the chances a child of a particular age has of spontaneous closure. It appears that the younger the child, the greater his chances. Two of the VSDs did close relatively late, after the age of 16 and 17. The size of the VSD plays a part in determining the chances of closure. While smaller VSDs are more likely to close, larger VSDs may also follow the same course: 58 out of the 215 VSDs in group I (27%) closed completely; 37 out of 133 VSDs in IIa (28%) closed completely (10 cases) or partially (27 cases); eight out of 82 VSDs in group IIb (10%) closed completely (one case proved by two catheterizations) or partially (seven cases). We have observed no closures among the VSDs in groups III and IV.

Case Details

Personal Characteristics

6-year-old female nonidentical twin, was delivered 3 weeks prematurely by cesarean section. The birth weight was 1.8 kilograms (4 pounds).

Clinical Characteristics

A systolic murmur was heard at 5 weeks of age. Congestive heart failure was first diagnosed at 8 months of age on the basis of failure to thrive, irritability, dyspnea, hepatomegaly and cardiomegaly. The clinical diagnosis of a ventricular septal defect was made, but patent ductus arteriosus was also considered in the differential diagnosis.

Remission Characteristics

At the age of 4 years and 7 months she was admitted to the hospital for recatheterization. At this time physical examination revealed that she was at the 25th percentile on the developmental chart by both height and weight. No chest deformity could be noted. Only a grade 1, early short systolic murmur was heard at the left sternal border.

Treatment & Mechanisms

Proposed Remission Mechanisms

Not discussed

Clinical Treatment

Oral administration of digoxin did not significantly ameliorate the symptoms. At 15 months of age, on account of her unsatisfactory response to adequate doses of digitalis and the possibility of the presence of a patent ductus arteriosus, she was admitted to the childrens hospital medical center for cardiac catheterization.

Additional Notes

This fifteen-month-old girl in congestive heart failure was shown at cardiac catheterization to have a large ventricular septal defect, with moderate pulmonary arterial hypertension. Repeat studies at four and a half years of age revealed virtual disappearance of the murmur, no left-to-right shunt detectable by oximetry and normal right ventricular pressures. Cineangiograms suggested the presence of a minute residual left-to-right shunt.