Swiss Cheese Defect of the Ventricular Septum

Additional Comment Is Necessary The Clinical Snapshot by Kloth et al. shows a very common anatomical particularity without any relevant pathological significance (1). In many pediatric cardiology practices and pediatric hospitals, such a clinical picture is presented almost on a daily basis: a young person with intermittent thoracic pain. The diagnostic evaluation by a pediatric cardiologist comprises the medical history, examination, ECG, if required long term and/or stress ECG, echocardi ography, and a cardiac cause can be ruled out in almost all cases. Computed tomography is absolutely redundant. The harmless muscular ventricular defect has nothing to do with the thoracic pain. A high spontaneous closure rate in this age group (14 years) is not to be expected, whereas in infants it is, up to the age of 10 in occasional cases. The classification of ventricular septum defects is not correct, and the term “Swiss cheese effect” is not used less often for atrial defects, but not at all. The decision about treatment depends on the hemodynamic relevance. And in such small defects there is no such relevance. DOI: 10.3238/arztebl.2020.0327a In Reply: The underlying question that prompted computed tomography scanning was whether the patient had a possible coronary anomaly (1). This arose after referral from the treating physician in private practice and prior diagnostic evaluation (including echocardiography). According to the consensus recommendations from 2012 (jointly set out by Diagnosis-Related Groups, the German Society of Cardiology (DGK), and the Germany Society of Pediatric Cardiology [DGPK]), this is a class I recommendation for undertaking coronary computed tomography—the indication was therefore in accordance with the guidelines. We did not intend to create the impression that the clinical symptoms were associated with the finding, which was clearly incidental. According to the literature, the spontaneous closure rate notably decreases after the 10 year of life; treatment seems unnecessary at the present time, but this is the responsibility of the treating pediatric cardiologists. We mentioned preventing endocarditis in order to underline the non-existent therapeutic relevance of this incidental finding. We are pleased that in responding to your comments we were given a broader opportunity to explain the importance of non-invasive cardiac imaging. “Swiss Cheese” Defect of the Ventricular Septum