acyanotic congenital heart disease - vsd - dr. gunasekaran

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

DISEASES OF THE CARDIOVASCULAR SYSTEM



Outlet (infundibular)(Supra cristal)

Membranous (80%)

Muscular(5-20%)

Inlet



Based on size:

Mild, Moderate, Severe:

0.5 cm, 0.5 -1 cm, >1 cm



RARVPV PALungsPVLAMVLVAortaOther parts of the body

What organic murmur? Why?

What flow murmurs? Why?

Which chamber gets enlarged? Position of AI? Type of AI?

Why recurrent RTI?



Symptoms in VSD

Small VSD:Asymptomatic; growth is normal;

Murmur - routine clinical examination.

Moderate to Large VSD: Breathlessness on exertion

Exercise intolerance

Feeding difficulties

Failure to thrive

Frequent RTI

Forehead sweating

Chest pain, palpitation, syncope ???



Vitals in VSD

Pulse: Volume? Rate? Character? Rhythm?

Blood pressure?

If there is CCF:



General examination

Undernourished, pallor +/-

Pedal edema, Pre sacral edema

Signs of I.E



Examination of heart

Inspection:

Precordial bulge (Cardiomegaly – Pliable chest)

Harrison sulcus +/-

Respiratory distress (CCF, LRTI)



Examination of heartPalpation:

Position of apical impulse

Shifted down & out (LV enlarge)

Type of apical impulse

Hyper dynamic

Palpate in the lower sternal area:

Thrill in 3, 4, & 5th LICS – Parasternal area

Palpate in the PA for the presence of PHT:

Palpable P2 ; also Systolic thrill



Examination of heart -AuscultationHeart sounds:

Usually normal

S1: loud (the cusps of MV are kept wide apart till the end of LV diastole)

S2 : may be widely split; but, varies with respiration.

Murmurs:

PSM – left lower parasternal area - grade 3,4 or 5(heard throughout the systole, as the pressure in the LV>RV)

Other possible murmurs: Flow murmurs –ESM at PA,MDM at MA – often drowned by the loud PSM



Complications

Congestive Cardiac Failure

Pulmonary Hypertension

Failure to thrive

Infective Endocarditis

Recurrent LRTI (for any LR shunt)

Eisenmenger’s syndrome



Complications Congestive Cardiac Failure:

Symptoms:

Gen Exam:

Vitals: Pulse:

BP:

Auscultation of Heart:

RS:

Abdomen examination:



ComplicationsCongestive Cardiac Failure:

Symptoms: Breathlessness, PND or Orthopnoea, cough

Gen Exam: Pedal edema

Vitals: Pulse:

BP:

Auscultation of Heart: Gallop

RS: Basal creps

Abdomen examination: Tender hepatomegaly



ComplicationsPulmonary Hypertension:

Palpable P2

P2 loud

Narrow S2

Ejection click + after S1 (dilated PA)

Soft & short systolic murmur (occassionally, followed by

EDM + due to Pulmonary regurgitation)



ComplicationsEisenmenger’s syndrome

In LR shunt; shunt reversal severe PHT & cyanosis

Can occur in all LR (VSD, ASD & PDA or Aortopulmonray shunts)

Usually occurs in non-restrictive lesions, in late teens age

If it occurs in VSD, then it is called as Eisenmenger Complex

If it occurs in VSD:

PSM Murmur intensity decrease

P2 becomes loud; Early Diastolic murmur +



Differential diagnosisTricuspid Regurgitation:



Natural History – What is the fate of VSD?Spontaneous closure :

Possible-small sized membranous, muscular (even large) and inlet

Outlet (of any size), large membranous with CCF: do not close

In smaller VSD: Risk of IE is more

In larger VSDs: Risk of CCF is more (8 weeks of age)

(Infundibular stenosis may develop: decrease in L R shunt: acyanotic TOF)



Investigations

Chest X Ray: Cardiomegaly, Increased PBF, Lung Infection

ECG: Chamber enlargement

ECHO:



ManagementMedical:

Anemia correction

Proper nutrition (feed frequently)

Dental Hygiene

Infective Endocarditis Prophylaxis

Treatment for Cardiac failure



Management - Surgical

Closure: Patch of woven dacron or PTFE

Decision based on

Size of defect

Size of shunt (LR)

CCF

PVR




Decision based on

Size of defect - Small

Size of shunt (LR)- Small (PBF:SBF <1.5:1)

CCF-Absent

PVR Normal

No need for Surgery; Only life-long IE Prophylaxis




Decision based on

Size of defect - large

Size of shunt (LR)- large (PBF:SBF >2:1)

CCF+ not responding to medical management

PVR slightly increased

Outlet defects- associated with aortic cusp prolapse

Surgery is indicated




Contraindications for surgery: severe PHT

PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion

> 12 wood units / m2 BSA



Syndromes associated with VSD

1. Chromosomal anomalies: Trisomies 21 (Down synd)

Trisomy 18 (Edward synd)

Trisomy 13 (Patau synd)

2. Syndromes: CHARGE, VATER, Cornelia-de-Lange

3. Maternal conditions: Phenytoin, Valproate, Diabetes

acyanotic congenital heart disease - vsd - dr. gunasekaran

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