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VENTRICULAR SEPTAL DEFECT (VSD)

Ventricular Septal Defect (VSD)

Most

common

(15-20%) defects

of

all (not

congenital

heart

including those forming cyanotic CHDs).

part of

VSD either involves membranous or muscular part of septum.

Ventricular Septal Defect (VSD)

VSD involving membranous septum also involves the adjacent muscular area peri-membranous VSD (70% of all VSDs). Muscular VSD can be inlet, outlet or trabecular defect.

Clinical Features
HISTORY

Small VSD

Asymptomatic

Moderate to large VSD Delayed growth


and development

Clinical Features

Low exercise tolerance Repeated chest infections CHF during infancy Longstanding VSD
PAH Cyanosis + low level of activity

Clinical Features
PHYSICAL EXAMINATION

Infants with small VSD well


developed and acyanotic.

Infants with large VSD may have


poor weight gain or shows signs of CCF.

Clinical Features

Reversal of shunt cyanosis and clubbing. Systolic border thrill at left lower sternal

P2 N with small shunt, accentuated with large shunt


Grade 2-5 holosystolic or early systolic murmur heard at left lower sternal border

INVESTIGATIONS
CXR
Cardiomegaly (LA, LV sometimes RV) Increased Pulmonary vascular markings. In POVD

Heart size is normal, Lung fields are ischemic,

Main pulmonary artery and hilar pulmonary artery segment enlargement.

INVESTIGATIONS
ECG
Small VSD: Moderate VSD: Large defect: In POVD: ECG is normal LVH, occ LAH BVH RVH only.

Echo
Diagnostic.

NATURAL HISTORY

During decrease

1st in

months and

of

life,

VSDs close

size

30-40%

completely (Exceptions: inlet or outlet

VSDs do not decrease in size or close


completely).

CHF develops in large VSD after 6-8 weeks of life.

NATURAL HISTORY

Infective Endocarditis is rare. POVD begins to develop by 6-12 mnths of age but R-L Shunt does not develop until teenage years.

MANAGEMENT
Medical No exercise restriction in the absence of PAH. Prophlaxis for IE needed. CHF is treated with diuretics and digoxin. Potassium sparing diuretics may be added. Frequent feeding with high calorie formulae. Anaemia should be corrected.

MANAGEMENT
Surgical Management Infants with small VSD and have reached 6 months of age without CCF or PAH No surgery needle. Indication for surgery Infants with large VSD who developed CHF and growth failure not respiratory to medical management. Surgery indicated within 6 months of age.

MANAGEMENT
Surgical Management Pulmonary artery pressure > 50% of systemic pressure VSD to be operated within 1st year of age. After one year of age Pulmonary flow: Systemic flow > 2:1. Older infants with large VSD and evidence of PAH should be operated as soon as possible. Infants with evidence of PAH but not CHF or growth failure should have cardiac catheterization at 6-12 months of age followed by surgery.

MANAGEMENT
Contraindications for Surgery

Pulmonary to systemic vascular resistance


ratio > 0.5.

Pulmonary vascular obstructive disease


with predominant R L shunt.

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