What are the different types of vsd?
The ventricular septum may be divided into a small membranous portion and a large muscular portion .
The muscular septum has three components: the inlet septum, the trabecular septum, and the outlet (infundibular or conal) septum. The trabecular septum (also simply called the muscular septum) is further divided into anterior, posterior, mid, and apical portions.
Therefore, VSD may be classified as a membranous, inlet, outlet (or infundibular), midtrabecular (or midmuscular), anterior trabecular (or anterior muscular), posterior trabecular (or posterior muscular), and apical muscular defect
Perimembranous: 80%;
Outlet or sub-pulmonary (doubly committed): 5%-7%;
Inlet: 5%-8%; and
muscular: 5%-20%,
these could be central (mid muscular), apical, marginal (anterior, septal-free wall area) or multiple, “swiss cheese” type.
What are the clinical manifestations?
Clinical Manifestations History
@ With a small VSD, the patient is asymptomatic with normal growth and development.
@ With a moderate to large VSD, delayed growth and development, decreased level of activity, repeated pulmonary infections, and CHF are relatively common during infancy.
@With long-standing pulmonary hypertension, a history of cyanosis and a decreased level of activity may be present.
What are the physical findings?
Infants with small VSDs are well developed and acyanotic. Before 2 or 3 months of age, infants with large VSDs may have poor weight gain or show signs of CHF. Cyanosis and clubbing may be present in patients with pulmonary vascular obstructive disease (Eisenmenger’s syndrome). 2.
A systolic thrill may be present at the lower left sternal border. Precordial bulge and hyperactivity are present with a large-shunt VSD. 3.
The intensity of the P2 is normal with a small shunt and moderately increased with a large shunt. The S2 is loud and single in patients with pulmonary hypertension or pulmonary vascular obstructive disease. A grade 2 to 5 of
6 regurgitant systolic murmur is audible at the lower left sternal border
). It may be holosystolic or early systolic.
An apical diastolic rumble is present with a moderate to large shunt (caused by an increased flow through the mitral valve during diastole
What are the ecg finding?
Electrocardiography
1. With a small VSD, the ECG is normal.
2. With a moderate VSD, left ventricular hypertrophy (LVH) and occasional left atrial hypertrophy (LAH) may be seen.
3. With a large defect, the ECG shows biventricular hypertrophy (BVH) with or without LAH
. 4. If pulmonary vascular obstructive disease develops, the ECG shows RVH only.
What are the x ray findings?
Cardiomegaly of varying degrees is present and involves the LA, left ventricle (LV), and sometimes RV. Pulmonary vascular markings increase. The degree of cardiomegaly and the increase in pulmonary vascular markings directly relate to the magnitude of the left-to-right shunt.
In pulmonary vascular obstructive disease, the main PA and the hilar PAs enlarge noticeably, but the peripheral lung fields are ischemic. The heart size is usually normal.
What is the role of echo?
Echocardiography Two-dimensional and Doppler echocardiographic studies can identify the number, size, and exact location of the defect; estimate PA pressure by using the modified Bernoulli equation; identify other associated defects; and estimate the magnitude of the shunt.
What is the management?
Medical
Small follow up
Medium to large :
diuretics
Ace inhibitors
+/- digoxin
Indications and Timing of Closure (All Class I recommendations)
Small VSD:
(No symptoms, normal PA pressure, normal left heart chambers, no cusp prolapse): (a) Annual follow-up till 10 years of age, then every 2-3 years; (b) Closure indicated if patient has an episode of endocarditis or develops cusp prolapse with aortic regurgitation or develops progressive significant right ventricular outflow tract obstruction.
Moderate VSD:
(a) Asymptomatic (normal pulmonary artery pressure with left heart dilation): Closure of VSD by 2-5 years of age; (b) Symptomatic: If controlled with medications, VSD closure by 1-2 years of age;
Large VSD:
(a) Poor growth/congestive heart failure not controlled with medications (furosemide/spironolactone or enalapril +/- digoxin): As soon as possible; (b) Controlled heart failure: By 6 months of age.
VSD with aortic cusp prolapse:
Any VSD with cusp prolapse and directly related aortic regurgitation that is more than trivial: Surgery whenever aortic regurgitation is detected.
What are the methods of closure?
Method of Closure
Surgery:
Conventionally patch closure is done. Pulmonary artery banding to be considered for patients with multiple VSDs, inaccessible VSDs and those with contraindications for cardio-pulmonary bypass.
Device closure:
For VSDs with adequate rims around defect and weight of child >8kg.
Superintendent, ICH.