DM cardiac anaesthesia

1. Kangkan sharma
NRS MEDICAL COLLEGE

2. • A VSD is a defect in the ventricular septum
• Most common congenital cardiac anomalies.
• 3-3.8 per 1000 live births
• 30-60% of all newborns with a CHD
• Prospective studies give a prevalence of 2-5
per 100 births of trabecular VSDs that closes
shortly after birth in 80-90% of the cases

3. • “Adevelopmental defect of the heart occurs from
which cyanosis does not ensue inspite of the fact
that a communication exists between the cavities
of the two ventricles and inspite of the fact that
admixture of venous blood and arterial blood
occurs. This congenital defect , which is even
compatible with a long life, is a simple one. It
comprises a defect in the interventricular
septum.”
Henri Roger, 1879

4.  Complex non – planar structure; 4
components
 Inlet septum – lightly
trabeculated; extends from
tricuspid annulus to attachments
of tricuspid valve
 Trabecular septum – heavily
trabeculated; trabecular septum
extends from inlet out to apex and
up to smooth-walled outlet
 Outlet septum – non trabeculated;
extends up to pulmonary valve&
diverge from small membranous
septum
 Membranous septum only fibrous
component of IVS, wedged btwn
AV,MV, TV.

5. 1.Membranous
2.Outlet
3.Trabecular septum
4.Inflow
5.Subarterial or
supracristal

6. • Most common congenital heart lesion
• Occurs in 50% of children with heart lesions
• 15-20% in isolation
• 5-50 per 1000 live births
• 56% female

7. • CLASSICAL
• SOTO
• VAN PRAAGH
• ANDERSON
• MORPHOLOGICAL (congenital heart surgery
nomenclature & database project)

8. CONAL
PARAMEMBRA
NOUS
ATRIOVENTRIC
ULAR CANAL
MUSCULAR

9. CONAL
CONOVENTRIC
ULAR
AV CANAL
MUSCULAR

10. PERIMEMBR
ANOUS
DOUBLY
COMMTTTE
D
MUSCULAR

11.  Classification
1. Perimembranous
Extension
inlet
outlet
anterior
2. Muscular outlet/conal
trabecular
inlet
anterior
apical
3. Doubly committed subarterial
4. Inlet septal
5. Malalinged
AV septal type
Ant (TOF)
Post(INTERRUPTED AORTIC ARCH)
Rotational (Taussig bing)

12. • Restrictive
• Moderately restrictive
• Non restrictive

13. – Restrictive- resistance that limits the shunt at the
site of vsd
– < 0.5 cm2 (Smaller than Ao valve orifice area)
– Small L to R shunt
– Normal RV output
– 75% spontaneously close < 2yrs
LVSP > RVSP
pulm /aortic systolic pressure ratio < 0.3
Qp / Qs<1.4--1

14. • Moderately restrictive - RVSP high, but
less than LVSP
• Qp/Qs 1.4--2.2

15.  Non restrictive -Shunt not limited at the site of
defect
– > 1.0 cm2 (Equal to or greater than to Ao valve
orifice area)
– Large hemodynamically significant L to R shunt
– Rarely close spontaneously
-RVSP , LVSP,PA , Aortic systolic
pressures equal
- Qp/Qs >2.2
- Flow determined by PVR

16. Small Size Medium Size Large Size
Diameter (mm)
Size (cm2)
<5
<0.5
5~15
0.5~1.5
>15
>1.0
Shunt small medium large
Symptom Non or little some Obvious
Pul. Vessel No affection affected Pul. Arterial
Hypertension
Eisenmenger’s
syndrome

18. • Defect size is often compared to aortic
annulus
– Large: > 75% of annulus size
– Medium: 75-33% of annulus size
– Small: <33% of annulus size

19. • Atrioventricular canal type VSD
• Muscular VSDs: midventricular
(1), apical (2), anterior (3), and
posterior (4)
• Conoventricular septal defect,
which includes
perimembranous and
malalignment conoventricular
septal defects
• Conal septal defects.

20. • Conoventricular defects are located between the conal
septum and the ventricular septum.
• They are centered in or around the membranous
 septum and comprise 80% of all VSDs.
• Located exclusively within the membranous
septum, or can extend beyond the boundaries
of the membranous
septum toward inferior, posterior, or
directions, and are then sometimes
anterior
called
“perimembranous” or “paramembranous” VSDs.

21. • The prefix “peri-,” appearing in loan words from the Greek,
means “surrounding” (i.e., perimeter). As such, a truly
perimembranous ventricular septal defect would surround
the membranous septum.
• In contrast, the prefix “para-,” also from the Greek, means
“adjacent to” or “beside” and more accurately reflects the
notion of a defect adjacent to the membranous septum.
• Neither perimembranous nor paramembranous correctly
describes the typical defect involving the membranous
septum and extending into the adjacent septum.

22. • The current recommendation is to call these defects either
membranous VSDs or conoventricular defects.
• Malalignment of
ventricular septal
the conal septal plane
plane results in
vis-à-vis the
the typical
conoventricular defect.
• The malalignment can be anterior, as seen in tetralogy of
Fallot, or posterior, as seen in interrupted aortic arch.
• Anterior conal septal malalignment also results in RVOT
• Posterior malalignment of the conal septum results in LVOT.

23. • Important landmarks in conoventricular septal defects are
the anteroseptal commissure of the tricuspid valve
inferiorly and the noncoronary cusp of the aortic valve.
• When the ventricular portion of the membranous septum
is entirely absent, the VSD extends to the base of the aortic
valve (sometimes called “subaortic” VSD).
• The medial papillary muscle (muscle of Lancisi) located at
the inferior–posterior border of the defect is also an
important landmark.
• Both the septal and anterior tricuspid valve leaflets are
attached to it.

24. • Approximately 8% of VSDs are located in the
conal (infundibulum or outlet) septum.
• They also are called supracristal VSDs.
• They are either entirely surrounded by muscle
(muscular conal VSDs) or limited upstream by
the aortic or pulmonary annuli (sometimes
called subarterial VSDs).

25. • This defect is characterized by the absence of
part or all of the inlet septum.
• The VSD is located immediately underneath
the septal leaflet of the tricuspid valve with no
tissue in between.
• Approximately 6% of all VSDs are inlet-type
VSDs.

26. • Muscular VSDs (10% of all VSDs) are entirely surrounded by
muscle.
• They can occur anywhere in the trabecular portion of the
septum and can be isolated or multiple.
• They are described by their location, that is, anterior,
midventricular, posterior, or apical.
• When inspected through the left side of the septum, what
appeared to be multiple muscular defects often converge
into either a single hole or two separate holes.

27. • Blood flow dependent on multiple factors
–Small and restrictive
• Lesion sizesize
–Large and non-restrictive
• BalanP
cu
elm
bo
en
ta
wry
eev
nasc
pu
ula
lr
monaryandresistance
systemic vascular resistance
systemic vascular
resistance

28. VSD shunt
Pulmonary
plethora
PAcongestive
RV
RA
SVC, IVC
Increased volume of
blood in pulmonay
circulation
LAenlargement
LV enlargement
Aorta ejects less blood
Systemic
circulation
insufficiency

29. SMALL VSD -
MODERATE / LARGE VSD - r :

30. Surgical
correction
has to be
done before
irreversible
damage to
pulmonary
vasculature
occurs.
Surgical correction
has to be done
before irreversible
changes in
pulmonary
vasculature occurs

32. 5 operative approaches - RIGHT ATRIAL
TRANSPULMONARY
TRANSAORTIC
RIGHT VENTRICULAR
LEFT VENTRICULAR
1.Preoperative vsd location
2.Surgical technique to avoid injury to conduction
pathways
3.Operative technique needed to secure the closure
5 operative approaches
Right atrial
Transpulmonary
Left ventricular
Right ventricular
transaortic

37. Thank you