Ventricular septal defect

Background

• A defect in the septum of the heart which separates the left and right ventricles
• Second most common congenital heart defect
• These defects can be isolated, due to chromosomal abnormalities (5%), or coexist with other heart defects such as Tetrology of Fallot
• Clinical presentation will vary depending on comorbid conditions

Clinical Presentation

• Small VSDs
  • Will generally be asymptomatic
• Moderate Size VSDs
  • May be asymptomatic
  • May develop heart failure symptoms in childhood or early adulthood
  • VSD may decrease in size without intervention as patient ages
• Large VSDs
  • Left-to-right shunts causing heart failure in infancy
  • may present with cyanosis, dyspnea, poor feeding, or failure to thrive
• VSD murmurs are best heard over the lower left sternal boarder
  • Characterized as a holosystolic murmur
  • Often, the small the defect, the louder the murmur

Differential Diagnosis

• Pulmonary stenosis
• Patent ductus arteriosis
• Tetrology of Fallot
• Aortic stenosis
• Tricuspid regurgitation
• Mitral Regurgitation
• Hypertrophic Cardiomyopathy

Evaluation

• Echocardiogram
  • This is the 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
• Electrocardiogram (EKG)
  • most patients with VSDs will have a normal EKG
  • conduction delay or RBBB may be seen in large defects
• Chest X Ray
  • typically normal in patients with VSDs
  • may show cardiomegaly with enlarged left ventricle and atrium

Management

• 40-60% of these defects require no intervention an will spontaneously close in early childhood
• Surgical closure (often done percutaneously) is the definitive treatment for defects that do not close on their own and cause significant disability
• Patient's with unrepaired VSDs are at increased risk for
  • endocarditis
  • Arrhythmias
    • Premature Ventricular Beats (PVCs)
    • Ventricular tachyarrhythmias
    • Sudden death
    • Congestive heart failure
    • Aortic regurgitation
    • COPD
    • Pulmonary Hypertension
• Treatment is aimed at reducing the complications associated with the VSD, as highlighted above

Disposition

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

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.