Vsd

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