VSD Flashcards
(45 cards)
What is the most common congenital cardiac malformation?
VSD
In what percentage of patient do VSDs occur?
32% of patients, either in isolation or with a range of other malformation
What four components is the ventricular septum made up of?
1) Membranous/Perimembranous
2) Trabecular/Muscular
3) Outlet/infundibular septum
4) Inlet/AV Canal/AVSD
What are the most common types of VSDs?
Perimembranous (80% of VSDs)
Where can perimembranous VSDs further extend to?
Inlet or outlet
How are outlet VSDs subdivided?
VSD outlet defect with anterior deviation of the outlet septum (e.g ToF, associated with aortic override) and those with posterior deviation (as seen with aortic arch interruption)
Where can Muscular VSDs be situated?
Completely surrounded by muscles; frequently multiple Inlet Trabecular apical or anterior part of septum
What is a sub arterial VSD = Outlet VSD = infundibular = supra cristal VSD?
Located beneath the semilunar valves in the outlet septum. Deficiency of infundibular septum resulting in an area of fibrous continuity between the semilunar valves. Often associated with progressive AR due to prolapse of the aortic cusp, usually right.
What factors affect the pathophysiology of a VSD?
Size of VSD
PVR relative to SVR, which determines magnitude and direction of flow through the defect
Effect of small VSD with a high resistance to flow
Small left-to-right shunt and minimal haemodynamic disturbance
Effect of large VSD with no pulmonary outflow tract obstruction
Large left-to-right shunt
Low PVR
High SVR
What increases a left-to-right shunt in a VSD?
Higher SVR (e.g. aortic coarctation)
or
LVOTO (e.g valvular, sub or supravalvular AS)
What causes the direction of the shunt to reverse in VSDs?
When PVR becomes higher than SVR
Clinical findings in Very small VSD
ESM at LSE
Clinical findings in small VSD
Thrill: +
Murmur: PSM loud LSE radiating to apex
Clinical findings in moderate VSD
Thrill: + Murmur: PSM, LSE to apex with mitral MDM Apex: LV+ S2 obscured by mitral ECG: LV+, LA+, LAD CXR: Increased CTR, plethora
Clinical findings in Large VSD
Thrill: No Murmur: ESM at upper LSE and mitral MDM Apex: LV+ , RV+ S2 single with increased P2 ECG: LV+, LA+, RV+ CXR: Increased CTR, plethora, prominent PAs
Clinical findings with pulmonary vascular obstructive disease (Eisenmenger)
Thrill: No Murmur: None or soft ESM Apex: RV++, palpable pA S2: Single loud palpable P2 ECG: RV+, RA++, RAD CXR: Increased CTR, no plethora, large central PAs
Where is an inlet VSD?
Inlet of the ventricular septum, immediately inferior to the AV valve apparatus, typically occurs in Down Syndrome
What determines direction and magnitude of VSD shunt?
PVR
Size of defect
LV/RV systolic and diastolic function
Presence of RVOTO
VSD clinical presentations in adults
- VSD operated in childhood without residual VSD
- VSD operated in childhood with residual VSD
- Small VSD with insignificant L-R shunt without LV volume overload or PHTN which was not considered for surgery in childhood
- VSD with L-R shunt, pHTN, LV volume overload
- Eisenmenger syndrome
Complications of residual VSD
- IE (2/1000 Pt years, 6x higher than normal population)
- Heart failure due to LV volume overload prolonged L-R shunt
- Double chamber RV
- Subaortic stenosis
- RCC prolapse –> AR
- arrhythmias inc CHB
Treatment Options for VSD
- Surgical closure (mostly pericardial patch) with good long-term results is the treatment of choice
- Transcatheter closure
Which patients should undergo surgical VSD closure?
1) Patients with symptoms that can be attributed to L-R shunting through the (residual) VSD and who have no severe Pulmonary Vascular disease
2) Asymptomatic patients with evidence of LV volume overload attributable to VSD
