VENTRICULAR SEPTAL DEFECT (VSD)

It is a hole on interventricular septum Congenital or acquired

VENTRİKÜLER SEPTAL DEFEKT (VSD)

Congenital• Isolated VSD can be seen in

nearly 2 per 1000 live births.

• It is the most frequent congenital cardiac anomaly.

• can be associated with other anomalies.

Acquired• It is mostly seen as a

complication of acute myocardial infaction.

• Rarely trauma is a cause .

VSD MORPHOLOGICAL CLASSIFICATION

Yerleşim

Perimembraneous %80

Subarterial %5-10( Juxta- arterial, conal, infundibular)

Muscular %5

Inlet septal <%5(AV kanal , AV septal)

Neighbourhood• Tricuspid valve , conduction

system (posteroinferior)

• Both semilunar valves ( Right coronary cusp)

• It is surrounded by muscle

• Conduction system (posteriorinferior)

VSD MORFOLOJİK SINIFLAMA

VSD MORFOLOJİK SINIFLAMA

CLASS ACCORDING TO SIZE

• VSD büyüklükleri; aort orifis çapına göre değerlendirilebildiği gibi

• VSD rezistans indekslerine (Rİ) göre de değerlendirilebilir.

• VSD Rİ = LVP - RVP x m2

• Qp-Qs

• LVP= Sol ventrikül basıncı; • RVP= Sağ ventrikül

basıncı; • Qp= Pulmoner kan akımı; • Qs= Sistemik kan akımı; • m2= Vücut alanı

VSD

Large VSD • VSD diameter ≥ Aortic

diameter

• VSD Rİ < 20 Ü/m2

• Resistance to flow is small

• RVP = LVP

• Qp/Qs ratio depends on degree of pulmonary vascular resistance (PVR).

Moderate VSD • VSD diameter < Aort

diameter

• RVP=1/2 LVP

• Qp/Qs≥2

VSD

Small VSD • VSD has not enough space

to increase the right ventricular sistolic pressure.

• VSD Rİ>20Ü/m²

• Qp/Qs<1.75

Symptoms and signs

• Patients with large VSD and increased Qp/Qs• Weak peripheral pulses• Tachypnea, subcostal drawings, profuse

sweating• Hepatomegaly, high jugular venous pressure, • Difficulty in feeding, growth retardation •

Large VSD and light PVR

• There is a strong pansystolic (holosystolic) murmur or thrill on the left parasternal region over the 3th ,4th intercostal space ( subarterial VSD on 2nd, 3th ICS),

• Apical diastolic murmur because of increased blood flow passing throughout th mitral valve.

• S2 is strong and splitted due to increased pulmonary flow.

Large VSD and high PVR

• Left to right shunt decreases and becomes bidirectional.

• Hyperactivity of the heart and cardiomegaly decrease.• Pansytolic murmur change in character, becomes

short and soft. • Apical diastolic murmur is no more heard. • S2 is forcefull. • The patient becomes cyanotic If PVR>SVR.

(Eisenmenger sendrome)

CHEST X-RAYLarge VSD and light PVR Large VSD and high PVR

Patients with Moderate size VSD

• Pansystolic murmur• Light – moderate left and right ventricular

enlargement.

small VSD

• There is harsh pansystolic murmur due to small VSD and shunt.

• EKG ve Chest X ray are normal.

Echocardiography:

• 2 Dimensional, colour Doppler ECHO• Give us incredible information about the

situation and size of the VSD• QP/QS can be calculated.• Associated anomalies like Aortic coarctation

and PDA .

HEART CATHETERIZATION

• To measure Pulmonary artery pressure, • Left to right shunt and PVR • To define the place, number and size of the

VSD • To show definitely the associatied anomalies.

SPONTANOUS CLOSURE

• Large VSD ;• 1 month %80 • 3 month %60 • 6 month %50 • 12 month %25 spontaneous closure chance.

SPONTANOUS CLOSURE

Less chance to close• Perimembranous• Juxta aortic• Inlet septal

More chance to close• Juxta-tricuspid• Muscular (outlet)

COMPLICATIONS

• Pulmonary Vascular disease

• Large VSD can have serious pulmonary resistance (Rp) in first 2 years of life

Pulmonary Vascular disease (Heath Edwards Classification)

• Grade 1: Medial hyperthrophy.• Grade 2: Medial hyperthrophy and intimal cellular

proliferation• ----------------------------------------------------------------------• Grade 3: Medial hyperthrophy and intimal fibrosis early

generalized vascular dilatation• Grade 4: Generalized vascular dilatation, vascular

oclusions due to intimal fibrosis, plexiform lesions.• Grade 5: Cavernous ve angiomatoid lesions.• Grade 6: Necrotizing arteritis.

Infective Endocarditis

• It is seen 0.15-0.3% of patient per year• More often small and moderate VSDs• Right sided vegetations (Tricuspid kapak)• Lung infections

• Aortic insufficiency• In the first decade 35-80 % .• Especially subarterial VSD

Early Death

• 9 % of the patient with large VSD die within the 1st year.

• PDA, Coarctation, large ASD• Recurrent lung infections (Viral).• Pulmonary edema (heart failure).• After the first decade Eisenmenger

complications (Hemoptisis, polycytemia, cerebral emboli, abscesses, right heart failure)

• 50% of patients die before 35 years of age.

Pulmonary Vascular Resistance

• Resistance• < 4 ünite m2 Normal• < 5 ünite m2 mildly elevated• < 8 ünite m2 moderately

elevated• > 8 ünite m2 severely elevated

INDICATIONS FOR OPERATION

• Large VSD• Every patient with intractable heart failure under medical

treatment can be operated before 12 months.• (Swiss cheese – Pulmonary banding)• If there is growth failure or Rp >8ü m2 at 6 month, the

operation should be performed.( If Rp < 4ü m2 , the operation can be deferred untill 12 month.)

• After infancy Rp is truely and precisely measured. If Rp < 8ü m2 patient can be operated, If Rp >8ü m2 , after isoproteronol perfusion remeasurement should be made If Rp ≤ 7ü m2 patient can be operated,

INDICATIONS FOR OPERATION

• Moderate VSD• If Ppa 40-50 mmHg and Qp/Qs is about 3 Rp

is rarely elevates and we can wait for operation untill 5 years of age.

• Small VSD• İnfective endocarditis, ventrikül dysfunction is

rarely seen (After 10 years of age)

SURGICAL TREATMENT

• Pulmonary banding• 1-Swiss cheese septum with intractable heart

failure• Complications• Hospital mortality is high• Pulmonary stenosis, migration

PATCH CLOSURE

• Perikardial, Dacron and PTFE patches can be used for closure.

• Interrupted suture (Teflon pledgeted single) or continuous suture can be used.

• From the right atrium------ Perimembranous.• From the right ventricle----- subarterial• (Ventricular scar can cause RBBB, Arythmia

yüksek)

Rigth Atrium

Continuous suture

Right Ventriculotomy

Interrupted suture