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S4 W9-12 Congenital Heart Disease > Ventricular Septal Defects > Flashcards

Ventricular Septal Defects Flashcards

1
Q

Overview of VSDs?

A
  • Communication between LV and RV
  • Account for around 20-25% of CHDs
  • Usually L-R shunt (LVP > RVP)
  • Dilatation of left heart: increased blood volume to lungs = increased pul. venous return = left heart dilatation
  • May have right heart dilatation if associated PHTN
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2
Q

What are the four stages in formation of the ventricular septum?

A
  1. Stage One: Muscular IVS
  2. Stage Two: Inlet IVS
  3. Stage Three: Aorticopulmonary Septum
  4. Stage Four: Membranous IVS
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3
Q

What occurs during stage one of formation of IVS?

A
  • Muscular ventricular septum grows upwards from apex to base of ventricles
  • Growth stops once it reaches AV canal as trunks arterioles only communicated with primitive RV
  • If fusion occurs too soon, LV will be shut off from trunks arteriosus
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4
Q

What occurs during stage two of formation of IVS?

A
  • Truncus moves to central position and AV canal shifts centrally to divide tricuspid and mitral orifices
  • Trabeculations from inlet region of AV canal unite to form a septum which grows into LV cavity at a slightly different plane than primary muscular septum - this is the inlet IVS
  • Fusion of muscular and inlet septum forms bulk to muscular IVS
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5
Q

What occurs during stage three of formation of IVS?

A
  • Two ridges of tissue appear on either side of truncus arteriosus = conotruncal ridges
  • Conotruncal ridges grow towards each other in spiral direction - they fuse to form the aorticopulmonary septum
  • Aorticopulmonary septum divides truncus arteriosus into aorta and PA
  • Conal ridges grow inferiorly towards ventricles and fuse with endocardial cushions, muscular IVS and inlet IVS
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6
Q

What occurs during stage four of formation of IVS?

A
  • Last segment of septum to form is membranous IVS
  • Formation of membranous IVS results incomplete closure of interventricular foramen
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7
Q

What are the types of VSD from most to least common?

A
  1. Perimembranous VSDs (80% of all VSDs)
  2. Muscular VSDs (20% of all VSDs)
  3. Inlet VSDs (5% of all VSDs)
  4. Supracristal VSDs (5% of all VSDs)
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8
Q

Location of perimembranous VSDs?

A

Beneath aortic vale bordering septal tricuspid leaflet and inferior crust supraventricularis

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9
Q

Location of muscular VSDs?

A

Anywhere along trabecular septum, bordered only by muscle (often multiple)

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10
Q

Location of inlet VSDs?

A

Posterior and inferior to membranous IVS, beneath TV and MV

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11
Q

Location supracristal VSDs?

A

Anterior to membranous IVS and beneath semilunar valves

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12
Q

Which which types of VSDs may AR occur and why?

A

AR may occur with perimembraneous or supracristal VSDs due to distortion or incomplete support of aortic valve cusps or annulus

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13
Q

Mechanism for AR due to VSDs?

A
  1. In early systole, ejected blood from LV will be shunted through VSD
  2. Unsupported cusp and aortic sinus are sucked into LVOT by Venturi effect
  3. In diastole, intra-aortic pressure forces aortic valve leaflets to close but unsupported cusp gets pushed down into LVOT away from opposing coronary cusp, creating AR
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14
Q

Differentiating perimembranous vs supracristal VSDs?

A
  • Differentiated from PSAX
  • Perimembranous VSD 9-12 o’clock
  • Supracristal (outlet) VSD 12-3 o’clock
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15
Q

Aneurysmal tissue in perimembranous VSD?

A
  • Formation aneurysm tissue along RV side of perimembranous VSD frequently notes
  • Tissue displays characteristic ‘wind sock’ appearance
  • Progressive development of aneurysmal tissue often leads to spontaneous closure of these defects
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16
Q

Distinguishing VSDs in apical window?

A
  • Perimembranous: more anterior and therefore seen in apical 5 chamber
  • Inlet: more inferior and posterior so seen in apical 4 chamber
  • Muscular or trabecular: seen anywhere along muscular septum
17
Q

Clue to inlet VSD?

A

Atrioventricular (TV and MV) valves arising at the same level is a clue to inlet VSD

18
Q

Shunt direction in VSDs?

A
  • L-R shunting during systole most common as LVSP > RVSP
  • Diastolic gradient may also be seen; occurs when LVDP > RVDP
  • CW across VSD; observe systolic and diastolic gradient
19
Q

QP in VSD?

A
  • QP = pulmonary venous volume to or from lungs (will be greater than QS as includes blood volume from body plus volume shunted across VSD)
  • QP = SV RVOT
  • Can also be calculated from MPA or MV
20
Q

QS in VSD?

A
  • QS = systemic volume to or from body
  • QS = SV LVOT
  • Can also use ascending aorta or TV
21
Q

RVSP in VSD?

A
  • VSD velocity reflects pressure difference between and LV and RV during systole (4(Vvsd)^2 = LVSP - RVSP)
  • RVSP = SBP - 4(Vvsd)^2
  • The higher the VSD velcoity,the lower the RVSP
22
Q

Options for surgical VSD closure?

A
  • Simple suture closure
  • Patch closure
23
Q

Options for percutaneous VSD closure?

A

Amplatzer occluder devices

24
Q

Role of echo post VSD closure?

A
  1. Assessment of LV size and systolic function – want to see if LV size has returned to normal or decreased in size
  2. Detection of any residual shunts
  3. Evaluation of position of closure device (if closed via this method)
25
Q

What is the Gerbode defect?

A
  • Type of VSD - AV septal defect: occurs within atrioventricular septum
  • LV to RA shunt (don’t confuse with TR - significantly overestimated RVSP)
  • Acquired or congenital
  • Can occur secondary to IE of VSD or trauma, acute MI or AVR
  • Systolic velocity through Gerbode defect will be very high as jet reflects pressure difference between LV and RA during systole
26
Q

What is an atrioventricular canal defect (AVCD)?

A
  • Account for 3% of CHDs
  • Occurs due to maldevelopment of superior and inferior endocardial cushions
  • > 75% of AVCD patients have Downe syndrome
27
Q

What is AVCD characterised by?

A
  • Large inlet VSD
  • Large primum ASD
  • Common atrioventricular valve (one valve instead of MV and TV)
28
Q

Best echo views to assess AVCD?

A

Apical 4 chamber and subcostal 4 chamber best evaluate the cardiac crux

S4 W9-12 Congenital Heart Disease (10 decks)

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