Ventricular septal defect:

 Common, accounting for 30% of all cases, 1/500 births.

 This is a defect anywhere in the ventricular septum, usually
o Perimembranous (adjacent to the tricuspid valve) -67%
o Muscular (completely surrounded by muscle)
 Most conveniently be considered according to the size of the lesion.

Small VSD:
 Defect smaller than the aortic valve in diameter, perhaps up to 3mm.

Clinical features:

 Asymptomatic
 May have thrill at lower sterna edge.
 Loud pansystolic murmur at lower left sterna edge.
 Quiet pulmonary second sound

Investigations:

1. Echocardiography
 Demonstrates the precise anatomy of the defects.
 It’s possible to assess it’s hemodynamic effects by Doppler echocardiograph
2. CXR & ECG
 Normal, no findings.

Management:

 Most of these lesions will close spontaneously

This is ascertained by the:
 Disappearance of murmur
 Normal ECG
 Normal echocardiogram

 Whilst the VSD is present, prevention of bacterial endocarditis is attempted by:

 Maintaining good dental hygiene
 Antibiotic prophylaxis before dental extraction or any other operation where there will
be bleeding.
Large VSDs:
 Defects are the same size or bigger than the aortic valve.

Clinical features:

 Heart failure with breathlessness and failure to thrive after 1 week old
 Recurrent chest infections

 Active precordium
 Soft pansystolic murmur or no murmur
 Apical mid-diastolic murmur- from increased flow across the mitral valve after blood has
circulated through the lungs.
 Loud pulmonary second sound (P2) – due to raise pulmonary arterial diastolic pressure.

 Heart failure- tachypnoea, tachycardia, enlarged liver.

Investigation:

1. CXR
 Cardiomegaly
 Enlarged pulmonary arteries
 Increased pulmonary vascular markings
 Pulmonary oedema

2. ECG
 Biventricular hypertrophy by 2months of age
 Signs of pulmonary hypertension

3. Echocardiography
 Demonstrates: anatomical defects, haemodynamic effects and severity of pulmonary
hypertension.

Management:

1. Drug therapy for heart failure

 Diuretics
 Captopril

2. Surgical repair, usually performed at 3-6months of age in order to:

 Manage heart failure
 Manage failure to thrive
 Prevent permanent lung damage from pulmonary hypertension and high blood flow.
**there is always some degree of pulmonary hypertension in children with large left to right shunt. This
damage the lungs as in increased pulmonary blood flow and pulmonary hypertension will ultimately lead
to irreversible damage of the pulmonary capillary vascular bed.

This pulmonary vascular disease usually becomes established in the second year of life.

But, Eisenmenger’s syndrome with cyanosis due to intracardiac shunting from right to left, rarely evolves
until the second decades.

Prognosis:

Long term prognosis is good.

Except in the case of Eisenmenger’s syndrome, which many patients die in the second or third decade of
life.