Background <p>Ventricular septal defect is a common congenital heart defect. While surgical repair has been the standard, transcatheter and perventricular closures have emerged as minimally invasive alternatives.</p> Methods <p>We conducted a systematic review and network meta-analysis of randomized controlled trials. We searched PubMed, Embase, Cochrane Library, clinicaltrials.gov, and Google Scholar up to February 2026. Risk of bias was assessed using the Cochrane tool, and the certainty of evidence was evaluated with GRADE. We conducted pairwise random-effects meta-analyses for direct comparisons, followed by a frequentist random-effects network meta-analysis to indirectly compare transcatheter and perventricular closure.</p> Results <p>Seven randomized controlled trials involving 2,126 participants were included. Studies were conducted in China, Egypt, or Russia. No deaths were reported. Transcatheter and perventricular closures may reduce blood transfusion needs compared to surgical repair, but the evidence is very uncertain. Perventricular closure may reduce hospital stay and operative time but may increase tricuspid regurgitation risk, compared to surgical repair. No significant differences were observed in indirect comparisons of transcatheter and perventricular approaches. Certainty of the evidence was low to very low.</p> Conclusion <p>Current evidence suggests that transcatheter and perventricular approaches may be associated with a lower need for blood transfusion compared with surgical repair, while perventricular closure may also reduce length of hospital stay but may increase tricuspid regurgitation. However, the evidence is uncertain, precluding firm conclusions and highlighting the need for well-designed, adequately powered randomized controlled trials.</p> PROSPERO I Registration <p>CRD42024595282</p>