Ventricular Septal Defect - PN
Definition Ventricular septal defects (VSD) è openings in the ventricular septum and occur both in isolation and in conjunction with other
cardiac defects.
Anatomy The ventricular septum anatomically having two components è the membranous and the muscular septum.
Figure 1. Anatomy of ventrivular wall and classification of ventricular septal defect.
Classification Kirklin classification
Figure 2. Kirklin classification of ventricular septal defect.
1
, Based on anatomy:
1. Perimembranous/ paramembranous/ subaortic/ conoventricular (most common, -80% of VSDs)
2. Muscular/trabecular (up to 15- 20%)
3. Outlet type (5%)
4. Inlet/ AV canal/ AVSD type
Based on sized and hemodynamic:
1. Small or restrictive VSD (Maladie de Roger)
2. Moderate restrictive VSD
3. Large VSD
4. Eisenmenger VSD.
Prevalence VSD is the most common form of CHD, accounting for 15% to 20% of all CHDs, not including those occurring as part of cyanotic
CHDs.
Clinical History
features - It can be asymptomatic to severe heart failure. The signs and symptoms begin to develop, when the fetal pulmonary
hypertension (PH) starts declining sufficiently to permit left to right shunting.
- Small VSDs è asymptomatic and may be detected, because of the murmur on a routine health check- up. Older asymptomatic
children may be detected during routine school health check-up.
- Moderate VSDs è pulsations over the precordium or a thrill. Child may have mild tachypnea, cough during feeding and
fatigue. Sweating especially during feeding is frequent in infants below 6 months. They may also present with lack of adequate
growth and with one or more episodes of pneumonia. Older children may present with effort intolerance and fatigue.
- Large VSDs è symptoms due to CHF by 4 to 6 weeks, as the pulmonary vascular resistance (PVR) decreases. The symptoms
are increased respiratory rate (tachypnea), chest retractions, feeding difficulties with suck-rest-suck cycle, excessive
sweating of forehead, repeated respiratory infections and failure to thrive.
- Large VSD with high PVR è did not have much symptoms at rest, but with exercise may have symptoms, which include
exertional dyspnea, cyanosis, chest pain, syncope and hemoptysis
Physical Examination
- Infants with nonrestrictive VSDs with balanced shunts may become cyanotic on crying or exercise.
- In small VSD, a grade 2 to 5/6 regurgitant systolic murmur (holo- systolic or less than holosystolic) maximally audible at
the LLSB is characteristic. A systolic thrill may be present at the LLSB.
- In large VSD, an apical diastolic rumble is audible, which represents a relative stenosis of the mitral valve due to large
pulmonary venous return to the LA. The S2 may split narrowly, and the intensity of the P2 increases if pulmonary hypertension
is present.
- The infants with large shunts with CHF are malnourished with poor growth and development. These infants are tachypneic
with chest retractions and there is precordial bulge with bilateral Harrison sulcus.
- Adult with large VSD è cyanosis and clubbing finger.
2
Definition Ventricular septal defects (VSD) è openings in the ventricular septum and occur both in isolation and in conjunction with other
cardiac defects.
Anatomy The ventricular septum anatomically having two components è the membranous and the muscular septum.
Figure 1. Anatomy of ventrivular wall and classification of ventricular septal defect.
Classification Kirklin classification
Figure 2. Kirklin classification of ventricular septal defect.
1
, Based on anatomy:
1. Perimembranous/ paramembranous/ subaortic/ conoventricular (most common, -80% of VSDs)
2. Muscular/trabecular (up to 15- 20%)
3. Outlet type (5%)
4. Inlet/ AV canal/ AVSD type
Based on sized and hemodynamic:
1. Small or restrictive VSD (Maladie de Roger)
2. Moderate restrictive VSD
3. Large VSD
4. Eisenmenger VSD.
Prevalence VSD is the most common form of CHD, accounting for 15% to 20% of all CHDs, not including those occurring as part of cyanotic
CHDs.
Clinical History
features - It can be asymptomatic to severe heart failure. The signs and symptoms begin to develop, when the fetal pulmonary
hypertension (PH) starts declining sufficiently to permit left to right shunting.
- Small VSDs è asymptomatic and may be detected, because of the murmur on a routine health check- up. Older asymptomatic
children may be detected during routine school health check-up.
- Moderate VSDs è pulsations over the precordium or a thrill. Child may have mild tachypnea, cough during feeding and
fatigue. Sweating especially during feeding is frequent in infants below 6 months. They may also present with lack of adequate
growth and with one or more episodes of pneumonia. Older children may present with effort intolerance and fatigue.
- Large VSDs è symptoms due to CHF by 4 to 6 weeks, as the pulmonary vascular resistance (PVR) decreases. The symptoms
are increased respiratory rate (tachypnea), chest retractions, feeding difficulties with suck-rest-suck cycle, excessive
sweating of forehead, repeated respiratory infections and failure to thrive.
- Large VSD with high PVR è did not have much symptoms at rest, but with exercise may have symptoms, which include
exertional dyspnea, cyanosis, chest pain, syncope and hemoptysis
Physical Examination
- Infants with nonrestrictive VSDs with balanced shunts may become cyanotic on crying or exercise.
- In small VSD, a grade 2 to 5/6 regurgitant systolic murmur (holo- systolic or less than holosystolic) maximally audible at
the LLSB is characteristic. A systolic thrill may be present at the LLSB.
- In large VSD, an apical diastolic rumble is audible, which represents a relative stenosis of the mitral valve due to large
pulmonary venous return to the LA. The S2 may split narrowly, and the intensity of the P2 increases if pulmonary hypertension
is present.
- The infants with large shunts with CHF are malnourished with poor growth and development. These infants are tachypneic
with chest retractions and there is precordial bulge with bilateral Harrison sulcus.
- Adult with large VSD è cyanosis and clubbing finger.
2
