Ventricular septal defect (VSD) is an opening in the wall separating the left and right ventricles of the heart. There are four main types classified by location. VSDs are also classified by size as large, moderate, or small depending on the diameter of the defect and degree of left to right shunt. Symptoms include feeding difficulties, respiratory infections, and congestive heart failure. Signs include heart murmurs, cardiomegaly, and widened pulse pressure. Echocardiography is the primary diagnostic tool used to assess location and size of the defect. Treatment options include medical management for smaller defects and surgical closure for larger defects causing heart failure or pulmonary hypertension.

1. VENTRICULAR SEPTAL
DEFECT (VSD)

3. VSD – TYPES ( location )
• Location of the defect:
• Type I: Subarterial (outlet, subpulmonic,
supracristal or infundibular)
• Type II: Perimembranous (subaortic)
• Type III: Inlet
• Type IV: Muscular

4. VSD – TYPES (SIZE )
• Large (nonrestrictive):
• Diameter of the defect is approximately equal to diameter of the
aortic orifice
• Right ventricular systolic pressure is systemic
• Degree of left to right shunt depends on pulmonary vascular
resistance

5. • Moderate (restrictive):
• Diameter of the defect is less than that of the aortic orifice
• Right ventricular pressure is half to two third systemic
• Left to right shunt is >2:1

6. • Small (restrictive):
• Diameter of the defect is less than one third the size of the aortic
orifice
• Right ventricular pressure is normal
• left to right shunt is <2:1

7. VSD ‐ HEMODYNAMICS

9. CLINICAL FEATURES
SYMPTOMS
• Feeding difficulty
• Suck rest suck cycle (dyspnea on exertion)
• Recurrent respiratory tract infection
• Congestive cardiac failure- breathlessness, feeding difficulty, sweating
• Failure to thrive

10. SIGNS
• Tachypnea
• CHF- Tachypnea, tachycardia, dependent edema, hepatomegaly & raised
JVP
• Wide pulse pressure
• Cardiomegaly –shifted apex
• Hyperkinetic precordium with a systolic thrill at left sternal border
• Pansystolic murmur at left sternal border
• The murmur is characteristically loud, harsh or blowing

11. • S1 and S2 masked by PSM at left sternal border
• Widely split & variable S2 with accentuated P2
• S3 at the apex may be audible
• ESM at pulmonary wall (flow murmur)
• Mid diastolic murmur at apex (flow murmur)

12. Clinical assessment of size of defect
• Small size VSD: normal growth of the child; no cardiomegaly; no cardiac
failure
• Medium size VSD : there will be cardiomegaly & may develop cardiac failure,
when there is associated respiratory infection. MDM at apex implies
significant shunt (>2:1 shunt)
• Large size VSD: there will be heart failure, growth failure & frequent
respiratory tract infection.

14. MODE OF DIAGNOSIS
• Physical examination
• ECG
• X‐ray chest
• Echocardiography

15. INVESTIGATIONS
• In small asymptomatic VSD- ECG & X-ray are likely to be normal
• In symptomatic medium & large sized VSDs:
• X-ray: cardiomegaly, pulmonary vascular markings are increased,
prominent pulmonary artery segment seen, left atrial enlargement
(shadow in shadow on the right side of cardiac shadow)
• ECG: left ventricular enlargement of volume overload type, evidence of
right ventricular hypertrophy & enlargement of left atrium
• Echocardiography –assess location & size of VSD & blood flow across it

16. NATURAL HISTORY
• About 10% of large nonrestrictive VSDs die in first year, primarily due
to congestive heart failure.
• Spontaneous closure is uncommon in large VSDs.
• 30%‐40% of moderate or small defects (restrictive) close
spontaneously, majority by 3‐5 years of age.
• Decrease in size of VSD is seen in 25%.

17. COMPLICATIONS
• Congestive heart failure
• Pulmonary arterial hypertension
• Eisenmenger’s syndrome
• Right ventricular outflow tract obstruction
• Aortic regurgitation
• Infective endocarditis

18. TREATMENT
• Medical management
• Maintain nutrition – adequate calories
• Prevent or manage anaemia
• Treatment of respiratory infections
• Infection prevention- immunization with H.influenza type B,
streptococcus pneumonia whenever possible
• Treatment of CHF - Diuretics (furosemide & thiazide), Inotropes, ACE
inhibitors

19. • Surgical
• Indications
• CCF
• Large left to right shunt
• VSD associated with pulmonary stenosis, pulmonary arterial
hypertension , aortic regurgitation

20. VSD ‐ MODE OF CLOSURE
• Surgical closure.
• Device closure for muscular VSD in those weighing >15 Kg & For
Perimembranous VSD
• Pulmonary artery banding is indicated for multiple (Swiss cheese) , or
very large VSD, almost single ventricle , infants with low weight (<2
Kg), and those with associated co‐morbidity like chest infection .

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