Ventricular septal defect (VSD), a complex condition also known as a ventricular septal rupture (VSR), is fatal for 25% of patients within 24 hours of its formation. Essentially a tear or hole in the heart, VSD affects approximately 1 in 1,000 patients who don’t seek care within a week of experiencing heart attack symptoms. Nearly all those patients (97%) die within a year if they don’t receive care for this condition.
Different from a congenital VSD, which will typically close on its own, an acquired VSD that forms during a heart attack develops when the heart starves for blood and it begins to weaken and die. A rupture in the septum will almost always leak blood, further weakening the heart. Within several weeks, the affected heart muscle turns to scar tissue, which can cause heart failure or lead to death.
Although acquired VSDs can happen to any patient after heart attack, higher-risk groups for the condition include women, seniors, and patients with high blood pressure or chronic kidney disease. Symptoms can include bluish skin, lips, and fingernails; labored breathing; sweating; and extreme fatigue.
VSDs can often be avoided if patients go to the ER as soon as they detect heart attack symptoms. Without monitoring, however, a VSD can form and the patient's health will rapidly decline, resulting in advanced heart failure within a few months.
“At UT Southwestern’s William P. Clements Jr. University Hospital we offer percutaneous VSD closure, a catheter-based alternative to open heart surgery. We are, in fact, one of fewer than 10 Texas hospitals that offer this advanced procedure.”
One of fewer than 10 Texas hospitals
Open heart surgery for VSD can be risky – VSDs are not perfect holes, and suturing the affected tissue is like sewing through butter. If stitches can't hold, we can't do open heart surgery. That’s why at UT Southwestern’s William P. Clements Jr. University Hospital we offer percutaneous VSD closure, a catheter-based alternative to open heart surgery. We are, in fact, one of fewer than 10 Texas hospitals that offer this advanced procedure.
With percutaneous VSD closure, we guide a catheter from the groin to the heart and insert a small, permanent device to close the VSD. (See "Closing the VSD" section below.)
Both open heart surgery and the catheter-based procedure for VSD closure are complex, with a 50% mortality rate for the former and a 30% mortality rate for the latter. By comparison, most other open-heart procedures register a 1% to 5% mortality risk. But there is no question that when we get the right patient population soon enough – at least within two weeks after a heart attack – the percutaneous VSD closure is saving lives.
Hurry to admit, wait to operate
Treating VSD percutaneously requires a “hurry up and wait” strategy. If we operate too soon, the hole could expand larger than the closure device that we are attempting to close the hole with, ultimately causing more damage. If we wait too long, the patient's health may decline too much to save the heart. In some cases, kidney function decreases due to low blood flow. The patient might need dialysis to keep fluid off their kidneys or lungs, or perhaps mechanical support to maintain heart function, such as a balloon pump. Expertise is required to carefully time the performance of the procedure, which balances delicacy with a certain amount of force.
A January 2020 study found that operating within seven days of a heart attack resulted in a 54.1% mortality rate in patients with hemodynamic compromise. Operating after seven days dropped the death rate to 18.4%.
Suffice it to say, the monitoring process is a delicate balance that requires sharp clinical judgment – we wait to operate until we cannot wait any longer.
Closing the VSD
We first determine the precise size and location of the VSD using images of the heart taken from outside the chest (transthoracic echocardiogram) and from inside the throat (transesophageal echocardiogram). These images help us map the route to the heart.
Most catheter procedures stay within the venous system or the arterial system. To navigate the complicated logistics of VSD, we must create an arteriovenous (A/V) loop in which we access both. Under imaging, it looks as if we’re flossing the heart with the wire/catheter. The long loop provides a rail that makes it possible to insert and place the closure device.
This complex procedure takes approximately four hours and one to two surgeons. First, we make a small puncture in the patient's groin to access the femoral artery and vein. Then, the surgeon inserts a catheter that holds a long wire and a device called a post-infarct muscular VSD occluder. It resembles a mesh disk, which then gets compressed inside the catheter that is used for delivery.
Attached to one side of the device is a retractable cord. The surgeons use real-time imaging to carefully thread a wire into the left ventricle of the heart, enter the VSD, and cross the catheter into the right ventricle. Then, we snare the wire and slowly pull it through the exit vein in the leg, completing the flossing path.
Positioning the device is the most challenging part of the procedure. If we’re even a millimeter off, we may need to start over. Once the device is in position, we carefully expand the left side of the device and pull it toward the VSD.
When fully expanded, the device looks like an irregular dumbbell, with the "weights" inside each of the ventricles and the bar between. After each side is placed, we release the cable and slowly remove the catheter and wires.
The device remains in the heart permanently. Over time, the device will become incorporated into the heart tissue inside the ventricles to seal the hole. Then begins the long road to recovery.
Lengthy recovery
For every day a patient is sedentary with illness, it takes approximately a week to regain lost strength. This could mean several months of recovery for the patient after they have been discharged from the hospital.
So, after the VSD closure, patients must diligently perform physical therapy to rebuild their muscles and improve their nutrition.
UT Southwestern offers a strong Cardiac Rehabilitation program to help patients recover after heart surgery or heart failure. Our dietitians, physical therapists, and other specialists track the patient's progress, helping them grow stronger and reduce their risk of future heart problems.
Percutaneous VSD closure is a complex, major procedure – and a lengthy, strenuous experience that can be avoided – which is why we urge patients to go to the emergency room at that first sign of heart attack. Whether they’ve made it to the ER or not, monitoring is needed in all such cases.
About the Author
Anthony Bavry, M.D., M.P.H., is a Professor of Internal Medicine at UT Southwestern and the Heart Valve Director at UTSW’s Clinical Heart and Vascular Center. An interventional cardiologist, he specializes in transcatheter aortic and mitral valve procedures. He has edited and contributed to numerous books and published scores of peer-reviewed articles on these and other structural heart interventions.
