When an ultrasound reveals a ventricular septal defect in the heart, does it always require immediate surgical management? We have found that many parents have such doubts. I will put together the common types of ventricular septal defects that require surgical management in the clinic, and hope to clear your doubts. 1.Large ventricular septal defect with pulmonary hypertension Large ventricular defects with pulmonary hypertension usually require early surgical management. However, the ultrasound diagnosis of pulmonary hypertension at this time is not necessarily due to a ventricular septal defect because of the physiological pulmonary hypertension period in the first 3 months of life. Only the ultrasound assessment of increased pulmonary artery pressure after 3 months of life is accurate. For example, a 1-month-old child with a 4-mm diameter ventricular septal defect combined with pulmonary hypertension detected on ultrasound may no longer have pulmonary hypertension when the ultrasound is repeated beyond 3 months of age due to decreased pulmonary resistance. If the ventricular septal defect is perimembranous and still less than 5 mm in diameter at this time, because the fractional flow is not large and there is a possibility of spontaneous healing due to the formation of a pseudoseptal tumor, and if there are no recurrent whistling infections or significant growth restriction, the child can continue to follow up with cardiac ultrasound without surgery for the time being. In children older than 3 months, a ventricular septal defect combined with pulmonary hypertension on ultrasound indicates high abnormal fractional flow in the heart, pulmonary congestion, growth retardation, and significant impairment of cardiac function, so early surgery is advisable. However, if the child has already developed shortness of breath, recurrent whistle infections, and severe feeding difficulties within 3 months of age, surgery may not be possible until after 3 months. There is also an extreme case in which an older child has an irreversible increase in pulmonary vascular resistance due to long-term pulmonary hypertension and a persistent right-to-left shunt, which is clinically referred to as “Eisenmenger syndrome”, and which cannot be repaired. It is also because the long-term pulmonary hypertension caused by large ventricular septal defects can lead to damage to the pulmonary vascular bed and cardiac function, so early surgical treatment is needed. If the ultrasound indicates that the ventricular defect is located under the pulmonary artery, first of all, this kind of ventricular defect will not heal naturally, and it is usually close to the right coronary valve of the aorta, which will easily lead to prolapse of the right coronary valve of the aorta and aortic regurgitation, so it needs to be operated early, and once it causes severe aortic regurgitation, it will complicate the simple problem and greatly increase the difficulty of surgical treatment. If ultrasound suggests that the aorta is riding over the ventricular septal defect, this ventricular defect is likewise not self-healing and also requires surgical intervention. These types of ventricular defects should not be treated by cardiology interventional occlusion because the occlusion device is likely to trigger aortic regurgitation. If the perimembranous ventricular septal defect has a high velocity left ventricular-right atrial shunt, or a diffuse shunt, or is close to the aorta without a coronary valve causing aortic valve prolapse and regurgitation, these conditions often indicate that the ventricular defect cannot heal spontaneously or is prone to aortic valve regurgitation, which often requires surgical intervention. 4. Combination of other cardiac and macrovascular malformations Ventricular septal defect often coexists with other intracardiac malformations, and early surgery is required if it is combined with moderate or higher valvular regurgitation or aortic constriction. Ventricular septal defect is also often part of a complex cardiac malformation, in which case it is not a simple ventricular septal defect and is treated according to the principles of management of all types of complex malformations. 5.Management of myocardial ventricular septal defect Some myocardial ventricular septal defects coexist with perimembranous ventricular defects, and some patients only have myocardial ventricular septal defects. In the case of muscular ventricular defect, sometimes it is difficult to be treated by both medical interventional sealing and surgical suturing, and requires inlay treatment with a ventricular defect sealer by the surgeon during surgery. For small muscular ventricular defects up to 3 mm in diameter, if the fractional flow is small and difficult to manage intraoperatively, they can be preserved, and follow-up ultrasound suggests that some children can gradually decrease or disappear as the muscular part of the ventricular septum develops. In children with multiple large myocardial ventricular defects, the management is more difficult, and sometimes only palliative pulmonary artery circumferential reduction can be performed to control intracardiac shunts, limit pulmonary artery pressure, and improve cardiac function without surgical repair of the ventricular defect. Such children often require early pulmonary artery annuloplasty because of large shunts and heavy pulmonary hypertension, and the surgical risk is often extremely high if they wait until the heart is significantly dilated and cardiac function is approaching failure. The above is a personal summary of the principles of management of common clinical ventricular septal defects. Personal experience inevitably has limitations, and the diagnosis and management of precardiac disease is indeed difficult to summarize in simple words because of the complexity of the disease and the uneven level of cardiac ultrasound diagnosis in different hospitals. If there are still doubts, you can contact a professional doctor for further consultation.