Acyanotic Congenital Heart Disease - VSD - Dr. Gunasekaran

1. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
DISEASES OF THE CARDIOVASCULAR SYSTEM

2. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD

3. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Outlet (infundibular)(Supra cristal)
Membranous (80%)
Muscular(5-20%)
Inlet

4. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Based on size:
Mild, Moderate, Severe:
0.5 cm, 0.5 -1 cm, >1 cm

5. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD

6. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
RARVPV PALungsPVLAMV LVAorta
Other 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?

7. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
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 ???

8. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Vitals in VSD
Pulse: Volume? Rate? Character? Rhythm?
Blood pressure?
If there is CCF:

9. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
General examination
Undernourished, pallor +/-
Pedal edema, Pre sacral edema
Signs of I.E

10. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Examination of heart
Inspection:
Precordial bulge (Cardiomegaly – Pliable chest)
Harrison sulcus +/-
Respiratory distress (CCF, LRTI)

11. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Examination of heart
Palpation:
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

12. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Examination of heart -Auscultation
Heart 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

13. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Complications
Congestive Cardiac Failure
Pulmonary Hypertension
Failure to thrive
Infective Endocarditis
Recurrent LRTI (for any LR shunt)
Eisenmenger’s syndrome

14. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Complications
Congestive Cardiac Failure:
Symptoms:
Gen Exam:
Vitals: Pulse:
BP:
Auscultation of Heart:
RS:
Abdomen examination:

15. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Complications
Congestive 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

16. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Complications
Pulmonary 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)

17. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Complications
Eisenmenger’s syndrome
In LR shunt; shunt reversal severe PHT & cyanosis
Can occur in all LR (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 +

18. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Differential diagnosis
Tricuspid Regurgitation:

19. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
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)

20. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Investigations
Chest X Ray: Cardiomegaly, Increased PBF, Lung Infection
ECG: Chamber enlargement
ECHO:

21. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management
Medical:
Anemia correction
Proper nutrition (feed frequently)
Dental Hygiene
Infective Endocarditis Prophylaxis
Treatment for Cardiac failure

22. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Closure: Patch of woven dacron or PTFE
Decision based on
Size of defect
Size of shunt (LR)
CCF
PVR

23. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Decision based on
Size of defect - Small
Size of shunt (LR)- Small (PBF:SBF <1.5:1)
CCF-Absent
PVR Normal
No need for Surgery; Only life-long IE Prophylaxis

24. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Decision based on
Size of defect - large
Size of shunt (LR)- large (PBF:SBF >2:1)
CCF+ not responding to medical management
PVR slightly increased
Outlet defects- associated with aortic cusp prolapse
Surgery is indicated

25. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
Management - Surgical
Contraindications for surgery: severe PHT
PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion
> 12 wood units / m2 BSA

26. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD
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

27. Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - VSD