Ventricular septal defect (VSD) is the most common congenital heart defect, occurring when there is an abnormal opening in the dividing wall between the ventricles. VSDs range in size from a few millimeters to defects so large there is no interventricular septum. They are typically classified based on location, size, number, and associated conditions. While small VSDs may close spontaneously, moderate or large VSDs can cause heart failure in infants and children if left untreated. Surgical closure of the defect is usually recommended for larger VSDs with significant left-to-right shunting or those accompanied by other heart issues like pulmonary hypertension.

1. Ventricular Septal Defect
(VSD)
Meru Yale

4.  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

5. Embryology

6. embryology

7. Classification
according to number
 Single VSD  Multiple VSD
 (Swiss-cheese type)

8. 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

9. According to site
 Supracristal
 Infracristal
membranous muscular
inlet trabecular infundibular

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

11. Haemodynamics

13.  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.

17. 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.

18. 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

19. General examination
 Pulse
small vsd-normal
moderate vsd-normal
large vsd with CCF- pulsus alternans
 JVP
increased with large vsd with CCF

20. 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

21. 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

22.  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

23. INVESTIGATIONS
 ECG
 Moderate VSD –
 Large 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
• Right axis deviation
• Biventricular enlargement- tall R in V1, deep Q in V5 and V6
• V3/V4 – equiphasic RS complex
• RBBB may be seen

25. 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.

26. X-RAY
 Moderate VSD –
 Large VSD –
• Mild – moderate cardiac enlargement
• Mild prominence of pulmonary artery
• Increase in pulmonary vasculature
• Significant cardiomegaly with left atrial enlargement
• Right atrial enlargement(with CCF)
• Dilated pulmonary artery
• Pulmonary plethora

28. 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.

29.  Eisenmenger’s complex
• Minimal cardiomegaly
• Oligaemic lung fields with central plethora
• Moderately dilated pulmonary trunk

30.  ECHO – site and size of defect can be visualized.
 Cardiac catheterisation-
 Doppler study detects direction of flow of blood across shunt.
• Visualisation of defect
• Oxygen studies
• Pressure studies

31. Complications
 CCF
 Pulmonary HTN
 Eisenmenger’s syndrome
 AR
 IE

32. Treatment
 Small VSD require no treatment – close spontaneously
 Operative correction is indicated in Qp:Qs ratio >1.5:1.0
 Medical
• Control CCF
• Treat repeated chest infections
• Anemia
• IE
 Surgical
• In CCF
• Large L R shunt
• Associated PS, pulmonary HTN, AR
 Closure of VSD with a patch
 Catheter closure of VSD is best for muscular defects

33. Thank You