ECHOCARDIOGRAPHIC EVALUATION OF VSD

1. CHOCARDIOGRAPHIC EVALUATION IN VENTRICULAR SEPTAL DEFEC

2. ECHO: VENTRICULAR SEPTAL DEFECT (VSD)
• DEFICIENCY IN INTER-VENTRICULAR SEPTUM (IVS) CREATES A COMMUNICATION
BETWEEN LV AND RV CALLED AS VENTRICULAR SEPTAL DEFECT (VSD
• BLOOD FLOWS FROM LV (HIGHER PRESSURE) TO RV (LOWER PRESSURE)
CREATING A LEFT-TO-RIGHT SHUNT ACROSS THE VSD.
• VSD MAY BE AN ISOLATED LESION OR ASSOCIATED WITH OTHER
ABNORMALITIES SUCH AS TETRALOGY OF FALLOT.
• RARELY VSD MAY BE ACQUIRED FOLLOWING ACUTE MYOCARDIAL INFARCTION
AND CALLED AS VENTRICULAR SEPTAL RUPTURE (VSR).

3. TYPES OF VSD
BASED ON
LOCATION
1. PERIMEMBRANOUS VSD
2. MUSCULAR VSD (TRABECULAR
VSD)
3. CONAL SEPTAL VSD (OUTLET
VSD)
4. ATRIO-VENTRICULAR (AV)
CANAL VSD (INLET VSD)
BASED ON SIZE :
1. SMALL VSD (< 0.5 CM) (OFTEN
CLOSE SPONTANEOUSLY)
2. LARGE VSD (> 1.0 CM) (90%
NEED SURGERY)
BASED ON
HEMODYNAMICS
1. RESTRICTIVE VSD
2. MODERATELY RESTRICTIVE
VSD
3. NON RESTRICTIVE VSD

4. ECHO ASSESSMENT OF VSD
2D
INSPECT THE INTERVENTRICULAR SEPTUM IN
AS MANY VIEWS AS POSSIBLE..
USE 2D ECHO TO AS- SESS THE STRUCTURE
OF THE INTERVENTRICULAR SEPTUM:
• IS THERE ANY ECHO DROPOUT IN THE
SEPTUM TO INDICATE A DEFECT?
• DESCRIBE THE TYPE OF VSD ACCORDING
TO ITS LOCATION
((PERI-)MEMBRANOUS, MUSCULAR, INLET OR
SUBPULMONARY).
• ASSESS WHETHER MULTIPLE DEFECTS ARE
PRESENT
• MEASURE THE SIZE OF THE VSD
• ASSESS RV SIZE AND FUNCTION – IS IT
DILATED AS A CONSEQUENCE OFA LEFT-TO-
RIGHT SHUNT?
COLOR
• ASSESS LA SIZE – IS IT DILATED
AS A RESULT OF VOLUME
OVERLOAD?
• ASSESS LV SIZE AND FUNCTION
(USUALLY NORMAL).
• USE COLOUR DOPPLER TO
CHECK FOR THE PRESENCE OF
FLOW ACROSS THE
INTERVENTRICULAR SEPTUM
DOPPLER
•
• IN THE SUBCOSTAL VIEW, USE CONTINUOUS
WAVE (CW) AND PULSED-WAVE (PW) DOPPLER
TO ASSESS FLOW ACROSS THE DEFECT.
• THERE IS USUALLY A HIGH-VELOCITY JET
FROM LEFT TO RIGHT VENTRICLE DURING
SYSTOLE, WITH LOWER-VELOCITY FLOW
DURING DIASTOLE
• IF YOU IDENTIFY A VSD, CHECK FOR ANY
ASSOCIATED ABNORMALITIES (E.G. AORTIC
CUSP PRO-LAPSE, AORTIC REGURGITATION).
• CHECK ALSO FOR THE PRESENCE OF
TRICUSPID AND/OR PULMO-NARY
REGURGITATION AND, WHERE POSSIBLE,
ASSESS PULMONARY ARTERY PRESSURE IN
CASE PULMONARY HYPERTENSION HAS
DEVELOPED.
• PERFORM A SHUNT CALCULATION TO
ESTIMATE THE SHUNT RATIO.

6. 2D ECHO
• VIEWS USED
COMMONLY PLAX, PSAX AND A4C VIEWS ARE USED
IN PLAX AND A4C VIEW: LA, LV DILATED
-LA, LV ARE SEEN DILATED DUE TO INCREASED VENOUS RETURN FROM
PULMONARY CIRCULATION CAUSING LV VOLUME OVERLOAD
• IVS ECHO DROP-OUT
IN A4C VIEW AND ALSO IN PLAX, PSAX VIEWS:
- DISCONTINUITY IN IVS IS SEEN AS AN ECHO DROP-OUT
- VSD MAY BE SMALL OR LARGE IN SIZE AND SINGLE OR MULTIPLE.

9. • PERIMEMBRANOUS VSD:
• OPENING IN UPPER SECTION OF IVS BELOW THE AORTIC VALVE CALLED THE MEMBRANOUS
SEPTUM.
• THIS IS THE MOST COMMONLY OPERATED TYPE OF VSD WELL SEEN I PLAX VIEW
• MUSCULAR VSD:
• OPENINGS IN THE MUSCULAR PORTION OF LOWER SECTION OF IVS.
• MOST COMMON TYPE OF VSD.CAN BE SINGLE OR MULTIPLE (SWISS CHEESE TYPE)
• LARGE NUMBER OF MUSCULAR VSDS CLOSE SPONTANEOUSLY AND DO NOT REQUIRE SURGERY.
• CONAL SEPTAL VSD: RAREST OF VSDS. ALSO CALLED SUBPULMONARY ,SUPRACRISTAL,
OUTLET OR DOUBLY COMMITED. OCCURS IN IVS JUST BELOW PULMONARY VALVE.WELL SEEN IN
PSAX.THIS TYPE OF VSD IS COMMONLY ASSOCIATED WITH AR DUE TO PROLAPSE OF RCC OF
AORTIC VALVE.
• ATRIOVENTRICULAR CANAL VSD: ASSOCIATED WITH AV CANAL DEFECT .ALSO KNOWN AS
INLET OR POSTERIOR TYPE.
• LOCATED POSTERIOR TO TRICUSPID SEPTAL LEAFLET. WELL SEEN IN A4C.
2D ECHO

10. • NO ECHO DROP-OUT IS OBSERVED IF THE DEFECT IS TOO SMALL (< 3 MM) IN
SIZE, IT IS ECCENTRIC IN DIRECTION OR IF IT IS MUSCULAR IN LOCATION, WHICH
SHUTS OFF DURING CONTRACTION IN SYSTOLE.
• -MULTIPLE AND SMALL DEFECTS GIVE THE SEPTUM A “SIEVE-LIKE” OR “SWISS-
CHEESE” APPEARANCE.
2D ECHO

13. COLOUR DOPPLER
• COLOR FLOW IMAGING SHOWS THE LOCATION OF VSD AS A MOSAIC JET AND
ALSO DIRECTION OF FLOW AS LEFT-TO-RIGHT SHUNT FROM LV TO RV, IN PLAX,
PSAX AND A4C VIEWS
• WIDTH OF THE COLOR FLOW MAP APPROXIMATES TO THE SIZE OF THE DEFECT

17. DOPPLER ECHO
ON CONTINUOUS WAVE (CW) DOPPLER,
A HIGH VELOCITY JET IS IDENTIFIED ACROSS THE VSD. FROM THE VELOCITY (V) OF THE
JET, THE PRESSURE GRADIENT (PG) BETWEEN LV AND RV CAN BE MEASURED USING
BERNOULLI EQUATION: PG = 4 V²
• HIGH VELOCITY JET WITH A HIGH PRESSURE GRADIENT INDICATES A SMALL RESTRICTIVE
VSD IN THE MUSCULAR PORTION.
• BY PULSED WAVE (PW) DOPPLER, THE HIGH VELOCITY ON CW DOPPLER AND COLOR
FLOW IMAGING CAN BE LOCALIZED AS TO WHICH PART OF SEPTUM THE VSD IS PRESENT.
WITH SIGNIFICANT VOLUME OF LEFT-TO-RIGHT SHUNT RV VOLUME OVERLOAD OCCURS
WITH RV DILATATION >23 MM AND PARADOXICAL MOTION OF IVS

18. DOPPLER CALCULATIONS
•
• PULMONARY ARTERY PRESSURE CAN BE ESTIMATED FROM TRICUSPID PEAK FLOW
VELOCITY AND PULMONARY HYPERTENSION IF ANY CAN BE IDENTIFIED.
• COMBINATION OF VSD WITH PULMONARY HYPERTENSION IS KNOWN AS
EISENMENGER SYNDROME.
• QUANTITY OF LEFT-TO-RIGHT SHUNT IS ESTIMATED FROM THE RATIO BETWEEN
PULMONARY AND SYSTEMIC STROKE VOLUME, WHICH IS THE QP/QS RATIO.
• A RATIO OF 1:1 INDICATES NO SHUNTING.
• (QS IS AORTIC OUTFLOW AND QP IS PULMONARY OUTFLOW.
• QP>QS SINCE A PORTION OF THE LV OUTPUT IS SHUNTED VIA VSD INTO RV)

19. DOPPLER CALCULATIONS
• THIS RATIO IS USEFUL IN THE EVALUATION OF PATIENTS WITH ATRIAL OR
VENTRICULAR SEPTAL DEFECTS AND IS BASED ON THE FOLLOWING FORMULAS:
• QP = RVOT VTI X Π X (RVOT/2)
• QS = LVOT VTI X Π X (LVOT/2)

25. ECHO ASSESSMENT FOLLOWING
VENTRICULAR
REPAIR
USING THE SAME VIEWS AS FOR UNREPAIRED VSD:
COMMENT ON THE PRESENCE OF A SEPTAL PATCH
CHECK FOR ANY RESIDUAL SHUNT
CHECK FOR AORTIC REGURGITATION (AFTER CLOSURE OF OUTFLOW TRACT VSD)
ASSESS LEFT HEART SIZE AND FUNCTION
ASSESS RIGHT HEART SIZE AND FUNCTION
ASSESS PULMONARY ARTERY PRESSURE.