Clinical Scenario:
A 4-month-old infant, born at term, presents with poor weight gain, sweating during feeds, and fast breathing since 6 weeks of age. Weight is 4.2 kg (<3rd centile), HR 160/min, RR 56/min, with a grade 4/6 pansystolic murmur at the left lower sternal border and a mid-diastolic apical rumble. Liver is palpable 4 cm below costal margin. Echo shows a 9 mm perimembranous VSD with left-to-right shunt, dilated LA/LV, and PA pressure ~60% of systemic. Despite 6 weeks of optimal diuretics and ACE inhibitors, the infant continues to fail to thrive and remains tachypneic.
What is the most appropriate next step in management?
A. Add digoxin, reassess in 4 weeks
B. Await spontaneous closure till 6 months
C. Cardiac catheterization before deciding
D. Refer for surgical closure
E. Start sildenafil therapy
Correct answer & Explanation:
Correct Answer: D — Refer for surgical closure
Explanation:
Why D is correct: Large VSD with heart failure and failure to thrive refractory to optimal medical therapy is an indication for surgical closure regardless of age, to relieve symptoms and prevent pulmonary vascular disease.
Why others are wrong:
- A — Digoxin adds little benefit; delays definitive treatment.
- B — Non-restrictive VSD with ongoing failure to thrive is unlikely to close spontaneously.
- C — Reserved for suspected elevated/irreversible pulmonary vascular resistance; not needed here (PA pressure ~60% systemic, echo sufficient).
- E — Used in inoperable Eisenmenger physiology, not as substitute for timely closure.
