V.S.D

Ventricular septal defect

Types :

1 – Acc.to site:

• Membranous ( the commonest ) .
• Muscular .
• Endocardial cushion defect .
• Sub – pulmonary defect.

2 – Acc to size :

• Small ( < Aortic Annulus )
• Moderate
• Large ( > Aortic Annulus )

3 – Acc.to significance :

• Singnificant shunt : Pul : Sys. flow → > 2 : 1
• Non – signif shunt : Pul : Sys. flow → < 2 : 1

4 – Acc.to.number :

• Single
• Multiple ( Swiss cheese )

Hemodynamic

1 – If Small: large resistance to Lt to Rt shunt → normal cardiac chambers & pulm v. bed
2 – If Large : minimal resistance

1. ↑ pulm . artery blood & pressure
2. lung plethora
3. biventricular enlargement.

RV ( Pressure Overloud)
LV ( Volume Overloud)

C/p

1 - if Small : ( Roger`s disease):
Symptoms : no
Signs :

• Normal S1 , S2
• Murmur : pansystolic murmur( Loud harsh or blowing heard over Lt 3rd, 4th parasternal area)
• Thrill : Propagated all over pericardium .

2 – if moderate :
as small +

• Slightly accentuated ( S2 → P2
• Apex : functional MS ( mid-diastolic tumbling murmur)

3 - If large :. N.B : No low COP in VSD
Symptoms

• dyspnea .

1. Recurrent chest infection . Feeding difficulties & low B.wt . Growth retardation .
2. HF in early infancy .
3. Long standing P.HTN → ↓ activity .

 
 Sings :
1 – palpation & percussion:

• Pericardial Bulge ( biventricular enlargement ) .
• Apex : shifted outward .& downward & Hyperdynamic
• Pulmonary .aretery : palpable S2 & dullness
• Epigastric area : pulsations ( RVE)
• Lt. parasternal : pulsation + thrill

2 – Auscultation:

• Leftt. parasternal area : pansystolic Murmur ( less harsh)
• Apex : short mid – diastolic rumbling
• Pulm. area : Accentuated P2 ( Pulmonary hypertension ) with narrow spitting .

Fate & C/O

1 - Spontaneous closure : in the first year of life & muscular > mem.
2 - Complications :
1 - Eisenmenger syndrome : reverse of the shunt → cyanosis & clubbing
2 - Biventricular failure
3 – infective endocarditis.
4 – Aortic regurge
5 – Arrhythmia
6 – haemoptysis
7 – recurrant chest inf

Investigations

1 – Chest X.ray : - Small : Normal
- Moder : LVE , LAE , P. HTN .
- Large : LVE , LAE , PVM , RVE , P. HTN
2 – ECG : as x-ray
3 - ECHO : Diagnostic
4- Catheterization: Đ & indicated in : Atypical Finding & ↑ PVR

Managemen

1 – small & moderate :

• Reassurance .
• Follow up for spontaneous closure.
• Prophylaxis against IE.

2 – large :
 1 – medical :
* ttt of chest infection & H.F .
* Prophylaxis Against IE .
- All patients : Amoxicillin oral .
- Allergy : Erythromycine oral .
- High risk group : Ampicillin IV + Gentamycin IV .
2 – surgical
* Indication : - No spontenous Closure .
- Significant defect .
- CHF in early infancy .
- PA pressure > 50 % of sys . blood P.
* Procedures: - Immediate surgical closure .
- Pulm . art . banding ( multiple & apical defects ) .