Download Ventricular Septal Defects

Dr. M. A. Sofi ME; FRCP (London);
FRCPEdin; FRCSEdin
Ventricular Septal Defect (VSD)
A ventricular septal defect (VSD) is a hole or a defect in the septum that
divides the 2 lower chambers of the heart, resulting in communication
between the ventricular cavities.
A. A VSD may occur as a primary anomaly, with or without additional major
associated cardiac defects.
B. It may also occur as a single component of a wide variety of intracardiac
anomalies, including tetralogy of Fallot (TOF), complete atrioventricular
(AV) canal defects, transposition of great arteries, and corrected
transpositions.
VSDs were first clinically described by Roger in 1879 ; the term maladie de
Roger is still used to refer to a small asymptomatic VSD.
In 1898, Eisenmenger described a patient with VSD, cyanosis, and pulmonary
hypertension. This combination has been termed the Eisenmenger
complex.
The most common form of CHD, accounting for up to 2040% of patients diagnosed with CHD
 Impact may range from asymptomatic to pulmonary HTN,
LV volume overload and RVH
 Morphology: 4 types
◦ Membranous – most common type in adults (80%)
◦ Muscular – most common type in young children
◦ Complete AV septal (endocardial cushion) defects
◦ Supracristal (subarterial)
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Epidemiology
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VSDs affect 2-7% of live births.
An echocardiographic study
revealed a high incidence of 5-50
VSDs per 1000 newborns.
The defects in this study were
small restrictive muscular VSDs,
which typically spontaneously
close in the first year of life
VSDs are the most common
lesion in many chromosomal
syndromes, including trisomy 13,
trisomy 18, trisomy 21, and
relatively rare syndromes
Sex-related demographics
 VSDs are slightly more
common in female patients than
in male patients (56% vs 44%).
Race-related demographics
 Reports are inconclusive
regarding racial differences in
the distribution of VSDs.
However, the doubly committed
or outlet defect occurs is most
common in the Asian
population. These constitute 5%
of the defects in the Unites
States but 30% of those reported
in Japan.
 Defect size is often
compared to aortic annulus
◦ Large: > 50% of annulus size
◦ Medium: 25-50% of annulus size
◦ Small: <25% of annulus size
Restrictive VSD is typically small, such that a significant
pressure gradient exists between the LV and RV (high velocity),
with small shunt
 Moderately restrictive VSD  moderate shunt
 Large / non-restrictive VSD  large shunt
 Eisenmenger VSD  irreversible pulmonary HTN and shunt
may be zero or reversed
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Restrictive: typically does not have hemodynamic impact
and may close spontaneously
◦ Location: Subaortic may result in progressive AI
 Moderately restrictive: does create LV overload and
dysfunction along with variable increase in PVR
 Large / non-restrictive: LV volume overload earlier in life
with progressive pulmonary hypertension and ultimately
Eisenmenger’s syndrome
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Symptoms:
Patients with ventricular septal defects may not have symptoms.
However, if the hole is large, the baby often has symptoms related
to heart failure
 Shortness of breath
 Fast heart rate
 Fast breathing
 Sweating while feeding
 Hard breathing
 Frequent respiratory
 Pallor
 Failure to gain weight
infections
Listening with a stethoscope usually reveals a heart murmur. The
loudness of the murmur is related to the size of the defect and amount
of blood crossing the defect.
 Chest radiograph, MRI, and ECG may all provide useful information
in the workup of a ventricular septal defect (VSD).
Tests may include:
 Cardiac catheterization (rarely needed, unless there are concerns of
high blood pressure in the lungs)
 Chest x-ray -- looks to see if there is a large heart with fluid in the
lungs
 ECG -- shows signs of an enlarged left ventricle
 Echocardiogram -- used to make a definite diagnosis
 MRI of the heart -- used to find out how much blood is getting to the
lungs
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Radiography:
Chest radiography may reveal the following:
Essentially normal-sized heart
 Small VSDs
 Normal pulmonary vascularity
Moderate or large VSDs
 Increased cardiac silhouette
 Increased pulmonary vascular
markings with a prominent main
pulmonary artery (PA) segment
 Enlarged left atrium (LA), which
is visible on lateral radiographs
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Large VSDs with markedly
increased pulmonary vascular
resistance (PVR)
 Right ventricular (RV)
hypertrophy with the cardiac apex
rotated slightly upward, to the
left, and posteriorly
 Markedly prominent main PA and
adjacent vessels
 Decreased pulmonary vascularity
in the outer third of the lung fields
Echocardiographic image of a moderate
ventricular septal defect in the midmuscular part of the septum
Ventricular septal defect
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Small VSD: no treatment may be needed. But closely monitored to
make sure that the hole eventually closes properly and signs of heart
failure do not occur.
Large VSD: who have symptoms related to heart failure may need
medicine to control the symptoms and surgery to close the hole.
Medications may include digoxin and diuretics.
If symptoms continue, even with medication, surgery to close the
defect with a patch is needed.
Some VSDs can be closed with a special device during a cardiac
catheterization, which avoids the need for surgery, but only certain
types of defects can successfully be treated this way.
Having surgery for a VSD with no symptoms is controversial.
Treatment
Most cases do not need treatment and heal at the first years of life.
Treatment is either conservative or surgical. Smaller congenital
VSDs often close on their own, as the heart grows, and in such
cases may be treated conservatively. Some cases may necessitate
surgical intervention, i.e. with the following indications:
1. Failure of congestive cardiac failure to respond to medications
2. VSD with pulmonic stenosis
3. Large VSD with pulmonary hypertension
4. VSD with aortic regurgitation
Symptomatic young infant with Pulm HTN
◦ Early surgery within 3 months.
◦ Medical therapy with diuretics +/- ACEI pre-op
 Asymptomatic pt without Pulm HTN but with LV overload
◦ Closure usually recommended to avoid late LV dysfunction
 Asymptomatic pt, small VSD, no LV dilation
◦ Conservative
 Asymptomatic pt, small VSD but with AI/ prolapse
◦ Peri-membranous VSD with more than trivial AI should
have surgery
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