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Practice Patterns in the Management of Pressure Restrictive Perimembranous Ventricular Septal Defects: A Multinational Survey

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Abstract

Indications for the closure of pressure restrictive perimembranous ventricular septal defects (pmVSD) are not well established in the pediatric population. We sought to assess practice variability among pediatric cardiologists in the United States (US), Canada, Australia, and New Zealand. A survey ascertaining practice patterns, including case vignettes with incremental progression of disease severity, was designed and administered through representative professional cardiac organizations and email listservs in the designated countries. Among the 299 respondents, 209 (70.0%) were from the US, 65 (21.7%) were from Canada and 25 (8.3%) were from Australia and New Zealand. Indications for pressure restrictive pmVSD closure included the presence of left ventricular (LV) dilation for 81.6% (244/299) (defined as z-score ≥ 2 for 59.0% (144/244) and ≥ 3 for 40.2% (98/244)) and significant pulmonary-systemic flow ratio (QP:QS) for 71.2% (213/299) [defined as ≥ 1.5:1 for 36.2% (77/213) and ≥ 2 for 62% (132/213)]. US pediatric cardiologists elected to close restrictive pmVSD at lower LV z-score and QP:QS ratio cut-offs (p-value 0.0002 and 0.013, respectively). In a case vignette, 63.6% (173/272) chose to intervene if there was right coronary cusp prolapse with stable mild aortic regurgitation. Of the remaining cardiologists, 93% (92/99) intervened if the aortic regurgitation was progressive (from trivial to mild). Commonly identified indications with variable thresholds for closure of pressure restrictive pmVSDs included the presence or progression of LV dilation, significant volume loading, and aortic valve prolapse with regurgitation. US pediatric cardiologists may have a lower threshold for pmVSD closure.

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Acknowledgements

The research team would like to thank the AAP SOCCS, the CPCA, the CSANZ, and PediHeartNet for distributing the survey on behalf of the research team to their members. Mr. Jesse Batara and Dr. Maryna Yaskina from the Women and Children's Health Research Institute (WCHRI) at University of Alberta provided statistical support for this project. The project data was collected and managed using REDCap hosted and supported by WCHRI and the research was funded by the generous support of the Stollery Children's Hospital Foundation through WCHRI.

Funding

There is no financial interest to report. The project was partially funded by the Stollery Children's Hospital Foundation through the Pediatrics Resident/Clinical Fellow Trainee Research Grant from the Women and Children's Health Research Institute at University of Alberta. The questionnaire and methodology for this study was approved by the Research Ethics Office at the University of Alberta (ID: Pro00108186).

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Authors and Affiliations

  1. Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, 8440-112th St. NW, Edmonton, AB, T6G 2B7, Canada

    Abdulrahman Alkanhal, Andrew S. Mackie & Michael Khoury

  2. Department of Cardiac Sciences, King Saud University, Riyadh, Saudi Arabia

    Abdulrahman Alkanhal

  3. Section of Cardiology, University of Manitoba, Winnipeg, MB, Canada

    Robin Ducas

  4. Division of Cardiology, Perth Children’s Hospital, Perth, WA, Australia

    Cameron Seaman

  5. Cohen Children’s Heart Center, Cohen Children’s Medical Center of New York, Zucker School of Medicine at Hofstra, New Hyde Park, New York, USA

    Konstantin Averin

  6. Division of Cardiology, BC Children’s Hospital, Vancouver, BC, Canada

    Kandice Mah

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Contributions

MK and KM conceived the presented idea. Under supervision of MK, AA reviewed the literature, designed the survey, collected the data and wrote the initial manuscript. RD, AM, CS, KA, KM and MK provided critical feedback and helped shape the research idea, the survey, analysis and manuscript. All authors participated in this work and reviewed and agreed with the content of this article. All authors meet criteria for authorship and have approved the final version of the manuscript.

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Correspondence to Michael Khoury.

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Alkanhal, A., Ducas, R., Mackie, A.S. et al. Practice Patterns in the Management of Pressure Restrictive Perimembranous Ventricular Septal Defects: A Multinational Survey. Pediatr Cardiol 44, 845–854 (2023). https://doi.org/10.1007/s00246-022-03073-x

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