Aortic Regurgitation Requiring Unplanned Surgery following Transcatheter Closure of Ventricular Septal Defect in Children: Incidence and Risk Factors

Zhang K, Yang P, Yin D, Li M, Liang X, Lv T, Zheng M, Xiang P. Cardiology. 2023;148(1):62-71. doi: 10.1159/000528115. Epub 2022 Nov 22. PMID: 36413978; PMCID: PMC10015750.

Take home points:

  • Transcatheter closure of a ventricular septal defect (VSD) may lead to significant aortic regurgitation (AR) requiring unplanned surgery.
  • Risk factors for unplanned surgery following transcatheter VSD closure include preprocedural mild AR, larger VSD size, infra-cristal VSD, and smaller sub-aortic rim (<2 mm)
  • Percutaneous device closure of VSDs in the absence of a clear indication may do more harm than good.

Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:

Ventricular septal defects (VSD) are one of the most common forms of congenital heart disease requiring intervention. Although surgical closure is more commonly performed, successful and safe transcatheter closure is increasingly reported in large series of selected patients. However, new-onset or worsening aortic regurgitation (AR) is an increasingly recognized complication. The authors of this retrospective study sought to determine the incidence and risk factors for significant AR requiring unplanned surgery following percutaneous device closure of VSD.

Between July 2009 and September 2018, 876 children (441 male, age 49.8 ± 29.8 months, weight 16.2 ± 6.4 kg) with isolated perimembranous VSD and no more than mild aortic valve prolapse or AR, underwent transcatheter VSD closure at Children’s Hospital of Chongqing Medical University. New-onset or increasing AR that was more than mild was diagnosed by both transthoracic color Doppler echocardiography and ascending aorta angiography. A total of 29 children (3.3%) required unplanned surgery, 6 due to new-onset and 23 due to increasing AR during the procedure. During a median follow-up of 7.3 years, no significant new-onset or increasing AR was seen in children who did not undergo unplanned surgery. Compared to those with ≤mild AR during the procedure, patients needing surgery had a higher proportion of aortic valve prolapse (69 vs. 12.3%), mild AR at baseline (79.3 vs. 2.4%), infracristal VSD (31 vs. 1.8%), asymmetric occluder use (51.7 vs. 9.6%), a larger VSD diameter by angiography (3.59 ± 1.80 vs. 4.45 ± 2.02 mm), a smaller sub-aortic rim (0.9 ± 1.0 vs. 3.5 ± 1.0 mm), higher PASP (34.5 ± 11.7 vs. 30.1 ± 8.7 mmHg), and a larger occluder size (7.4 ± 1.9 vs. 6.3 ± 1.5 mm). On univariate and multivariate logistic regression analyses, risk factors for new-onset or increasing AR requiring unplanned surgery were aortic valve prolapse, preprocedural mild AR, intracristal VSD, larger VSD diameter and smaller sub-aortic rim.

This retrospective single-center study including a large cohort of patients showed that significant AR developed in 3.3% of children undergoing percutaneous device closure of VSD. Unsurprisingly, preprocedural aortic valve prolapse or AR, intracristal VSD, and a larger VSD with a smaller sub-aortic rim were identified as risk factors. Unfortunately, the indications for VSD closure are not discussed and the patient data suggest that most patients had pressure restrictive perimembranous VSDs, where intervention may not be warranted. In addition, the term intracristal VSD is used to define a defect located at the 12:00-1:30 o’clock position in the transthoracic echocardiographic parasternal short-axis view, which is likely to correspond to an outlet VSD (whether perimembranous or doubly committed juxta-arterial) according to a more accepted nomenclature.1 These VSDs are more often associated with AVP or AR, and have a higher risk of complications during transcatheter closure, making the surgical option likely more appropriate. Finally, this study highlights the pitfalls of unchecked zeal to close pressure restrictive, mostly perimembranous VSDs, which is unsupported by clinical evidence.


  1. Lopez L, Houyel L, Colan SD et al. Classification of Ventricular Septal Defects for the Eleventh Iteration of the International Classification of Diseases-Striving for Consensus: A Report From the International Society for Nomenclature of Paediatric and Congenital Heart Disease. Ann Thorac Surg. 2018;106(5):1578-1589. doi: 10.1016/j.athoracsur.2018.06.020. Epub 2018 Jul 19. PMID: 30031844. ↩︎