Ventricular septal defect

Background

Ventricular septal defect

Illustration showing various forms of ventricular septal defects. 1. Conoventricular, malaligned; 2. Perimembranous; 3. Inlet; and 4. Muscular.

• Defect in septum separating left and right ventricles
• Second most common congenital heart defect
• Can be isolated, due to chromosomal abnormalities (5%), or coexist with other heart defects such as Tetralogy of Fallot
• Clinical presentations vary depending on comorbid conditions

Clinical Presentation

• Small VSDs
  • Generally asymptomatic
• Moderate Size VSDs
  • May be asymptomatic
  • +/- heart failure symptoms in childhood or early adulthood
  • May decrease in size without intervention as patient ages
• Large VSDs
  • Left-to-right shunts causing heart failure in infancy
  • Cyanosis, dyspnea, poor feeding, or failure to thrive
• VSD murmur
  • Best heard over the lower left sternal boarder
  • Characterized as a holosystolic murmur
  • Smaller defects produce louder murmurs

Differential Diagnosis

Non-Congenital Presentations

• Tricuspid regurgitation
• Mitral regurgitation
• Hypertrophic cardiomyopathy

Congenital Heart Disease Types

• Cyanotic
  • Tetralogy of fallot
  • Total anomalous pulmonary venous return
  • Transposition of the great arteries
  • Tricuspid atresia
  • Truncus arteriosus
  • Ebstein anomaly
  • Hypoplastic left heart syndrome
• Acyanotic
  • AV canal defect
  • Atrial septal defect (ASD)
  • Ventricular septal defect (VSD)
  • Cor triatriatum
  • Patent ductus arteriosus (PDA)
  • Pulmonary/aortic stenosis
  • Coarctation of the aorta
• Differentiation by pulmonary vascularity on CXR
  • Increased pulmonary vascularity
    • Large ASD
    • Large VSD
    • Total anomalous pulmonary venous return
    • Transposition of the great arteries
    • Truncus arteriosus
  • Decreased pulmonary vascularity
    • Tetralogy of fallot
    • Rare heart diseases with pulmonic stenosis

Evaluation

Echo showing a moderate ventricular septal defect in the mid-muscular part of the septum. Flow is from the left ventricle (right on image) to the right ventricle (left on image). The size and position is typical for a VSD in the newborn period.

• Echocardiography
  • Most important clinical test
  • High detection rate for VSD
  • Allows operator to visualize the defect and assess how much bloodflow is crossing the defect by using color flow Doppler
  • Allows for detection of other possible structural defects
  • Often used to follow VSDs for spontaneous closure
• EKG
  • Most patients with have normal EKGs
  • Large defects may produce conduction delays or RBBB
• CXR
  • Usually normal
  • May show cardiomegaly with enlarged left ventricle and atrium
  • May show signs of CHF

Management

• 40-60% require no intervention, will spontaneously close in early childhood
• Surgical closure (often done percutaneously)
  • Definitive treatment for defects that do not spontaneously close and cause disability
• Patients with unrepaired VSDs at increased risk for:
  • Endocarditis
  • Arrhythmia
    • Premature ventricular contractions (PVCs)
    • Ventricular tachyarrhythmias
    • Sudden death
    • Congestive heart failure
    • Aortic regurgitation
    • COPD
    • Pulmonary hypertension
• Treatment aimed at reducing complications

Disposition

• Suspected VSDs require workup by a cardiologist
• Once surgery becomes an option, surgical consultation is recommended

See Also

• Congenital heart disease

External Links

• Ventricular septal defects | circulation Retrieved 8/18/2017, 2017, from http://circ.ahajournals.org/content/114/20/2190
• Du ZD, Roguin N, Wu XJ. Spontaneous closure of muscular ventricular septal defect identified by echocardiography in neonates. Cardiol Young 1998; 8:500.