Ventricular Septal Defect

(VSD)

Meru Yale
 Most common congenital cardiac malformation
 25% of all CHD
 90% are in the membranous part of septum.
 VSD vary from a few mm in diameter ,to a defect so large –
no interventricular septum( single ventricle)
 Associated with ASD,PDA or PS
Embryology
embryology
Classification
according to number
 Single VSD  Multiple VSD
 (Swiss-cheese type)
According to size

 Small VSD - <0.5 cm2/m2 BSA

 Maladie de Roger- these defects close spontaneously.

 Moderate VSD is 0.5-1 cm2/m2

 Large VSD is >1cm2/m2

According to site

 Supracristal
 Infracristal

membranous muscular

inlet trabecular infundibular

Conditions associated with VSD

Chromosomal Anomalies
Maternal conditions
 Trisomy 21,18 13 • Diabetes
• Phenylketonuria
 Cri-du-chat syndrome
Syndromes Teratogenic agents
• Alcohol
 CATCH 22
• Hydantoin
 VATER • Valproate
 Holt Oram • Trimethadone

 CHARGE
Haemodynamics
 Right ventricle pressure is 1/5th left ventricle pressure- causes pressure
gradient across vsd.
 Magnitude of shunt depends on size of defect and pulmonary
resistance.
 In large vsd rt to lft ventricular pressure is equalized.in these defects
direction is determined by ratio of pulmonary to systemic vascular
resistance.
Natural History

 Spontaneous closure in 40% cases

 25-30% defects may become small enough not to require surgical intervention.
 Majority of defects close by age 2,most close by age 5-7yrs.
 Pulmonary vascular obstructive disease may develop in 10%
 Infundibular stenosis (Gasul’s transformation) may occur in 8%of the defects.
 Aortic insufficiency develops in 5% of patients.
Clinical Features
 It depends on size of VSD
 Small vsd- asymptomatic.
 Moderate to large vsd – symptomatic at 6-10 wks of age.
exercise intolerance
delayed growth
CCF
recurrent respiratory tract infection
cardiomegaly
 Large vsd with pulmonary HTN
cyanosis
clubbing
polycythaemia
General examination

 Pulse
small vsd-normal
moderate vsd-normal
large vsd with CCF- pulsus alternans
 JVP
increased with large vsd with CCF
CVS
 Inspection
small vsd- normal
moderate vsd- moderate parasternal lift
Large vsd- hyperdynamic precordium
 Palpation
small vsd – normal
moderate and large vsd-
• Precordium-prominent(cardiomegaly)
• Parasternal heave (RV hypertrophy)
• P2 palpable (pulmonary HTN)
• Thrill (systolic)- 3rd and 4th ICS
Auscultation

 Small vsd- S2 normal , pansystolic murmur.

 Moderate vsd- S1 loud at apex
S2 widely split
P2 is loud
S3 may be heard over apex
murmur grade 4-6 ,holosystolic at left sternal border
short systolic murmur in 2nd left ICS
middiastolic murmur flow murmur – mitral valve area
 Large VSD-

• S2 loud with loud P2

• PSM with thrill - lower left sternal border
• S3
• Mid-diadtolic rumble in apical area
• Murmur in upper left parasternal area
• Pulmonary ESM preceded by EC
INVESTIGATIONS
 ECG
 Moderate VSD –

• Left axis deviation

• Left atrial enlargement- notched p in lead I , aVR and V6
• Left ventricular enlargement – tall R in lead I, II and aVF
• Prominent Q and tall R in V5 and V6
 Large VSD-
• Right axis deviation
• Biventricular enlargement- tall R in V1, deep Q in V5 and V6
• V3/V4 – equiphasic RS complex
• RBBB may be seen
Tracing from a 3-month-old infant with a large ventricular septal defect, patent ductus arteriosus,
and pulmonary hypertension. The tracing shows
combined ventricular hypertrophy with left dominance. Note that V2 and V4 are in ½

standardization.
X-RAY
 Moderate VSD –

• Mild – moderate cardiac enlargement

• Mild prominence of pulmonary artery
• Increase in pulmonary vasculature

 Large VSD –
• Significant cardiomegaly with left atrial enlargement
• Right atrial enlargement(with CCF)
• Dilated pulmonary artery
• Pulmonary plethora
Posteroanterior and lateral views of chest roentgenograms of a ventricular septal
defect with a large shunt and pulmonary hypertension. The heart size is
moderately increased, with enlargement on both sides. Pulmonary vascular markings
are increased, with a prominent main pulmonary artery segment.
 Eisenmenger’s complex
• Minimal cardiomegaly
• Oligaemic lung fields with central plethora
• Moderately dilated pulmonary trunk
 ECHO – site and size of defect can be visualized.
 Cardiac catheterisation-
• Visualisation of defect
• Oxygen studies
• Pressure studies

 Doppler study detects direction of flow of blood across shunt.

Complications

 CCF
 Pulmonary HTN
 Eisenmenger’s syndrome
 AR
 IE
 Treatment
 Small VSD require no treatment – close spontaneously
 Operative correction is indicated in Qp:Qs ratio >1.5:1.0

 Medical  Surgical
• Control CCF • In CCF
• Treat repeated chest infections • Large L R shunt
• Anemia • Associated PS, pulmonary HTN, AR
• IE  Closure of VSD with a patch
 Catheter closure of VSD is best for muscular defects
Thank You