VENTRICULAR SEPTAL DEFECT by Dr.Amarnath BR BMC. CONGENITAL HEART DISEASE...
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VENTRICULAR SEPTAL DEFECT
by
Dr.Amarnath BRBMC
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CONGENITAL CONGENITAL HEART DISEASE HEART DISEASE
(con-together,genitus-born)(con-together,genitus-born)
The majority of congenital anomalies of the heart are
present 6wks after conception & most
anomalies compatible with 6mths of intrauterine life permit live offspring at
term.
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TYPES OF CHDTYPES OF CHD
•Gr 1 Lt to Rt shunts
•Gr 2 Rt to Lt shunts
•Gr 3 Obsructive lesions
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LEFT to RIGHT shuntsLEFT to RIGHT shunts(acyanotic heart disease)(acyanotic heart disease)
Frequent chest infections (6-8 attacks first year of life)
Tendency for increased sweating with related their tendency for developing CCF
Precordial bulge Hyperkinetic precordium Tricuspid /mitral DDM X-ray plethoric +cardiomegaly VSD,ASD, PDA,AVcanal
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RIGHT to LEFT shuntsRIGHT to LEFT shunts (cyanotic heart disease)(cyanotic heart disease)
increased pulm. blood flow * mildly cyanotic * increased sweating * CCF * FTT * plethoric lung fields * cardiomegaly *TGA,singlventricle,
TA,total anomalous pulm. Return w/o obstruction
decreased pulm.blood flow
* mod. to severe cyanosis * ESM, delayed and
diminished P2 (PS) * in PH ,accentuated &
palpable P2,ESM * oligemic lung fields * TOF,PA,TA,total
anomalous pulm. return w/ obstruction
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Obstructive lesionsObstructive lesions
• absence of frequent chest infections• absense of cyanosis
•
• absence of precordial bulge
• presence of forcible &heaving cardiac impulse
• systolic thrill +ESM & delayed corresponding S2
•ECG shows obstructive lesions
•X-ray normal sized heart & pulm. Vasculature
•pulm.stenosis(rt side) & aortic stenosis,coarctation of aorta(lt side)
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NADA’S CRITERIANADA’S CRITERIA
MAJORMAJOR• systolic murmur gr III
or more• diastolic murmur• cyanosis• ccf
one major &two minor are essential
MINORMINOR • systolic murmur less
than gr III• abnormal S2• abnormal ECG• abnormal X-ray• abnormal BP
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VENTRICULAR SEPTAL VENTRICULAR SEPTAL DEFECTDEFECT
• most common ACHD
• 2nd most common CHD(32%)
• SYNONYMS
* Roger’s disease
* Interventricular septal defect
* congenital cardiac anomaly
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PATHOPHYSIOLOGYPATHOPHYSIOLOGY primarily depends on size&status of pulm. vascular bed rather than
location Small communication (less than 0.5cm`) VSD is restrictive &
rt.ventricular pressure is normal – does not cause significant hemodynamic derangement(Qp:Qs=1.75:1.0)
Moderately restrictive VSD with a moderate shunt(Qp:Qs=1.5-2.5:1.0) &poses hemodynamic burden on LV
Large nonrestrictive VSDs(more than 1.0cm`) Rt&Lt ventricular pressure are equalised(Qp:Qs is more than 2:1)
Large VSDs at birth ,PVR may remain higher than normal and Lt to Rt shunt may intially limited – involution of media of small pulm.arterioles,PVR decreases—large Lt to Rt shunt ensues
In some infants large VSDs ,pulm. arteriolar thickness never decreases –pulm.obstructive disease develops .when Qp:Qs=1:1 shunt becomes bidirectional,signs of heart failure abate &pt. becomes cyanotic. (Eisenmenger syndrome)
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ANATOMICALANATOMICALCLASSIFICATIONCLASSIFICATION
typeI-MEMBRANOUS SEPTUMMEMBRANOUS SEPTUM paramembranous/perimembranous defect (or infracristal,subaortic,conoventricular)typeII-MUSCULAR SEPTUMMUSCULAR SEPTUM inlet,trabecular,central,apical,marginal or swiss-cheesetypeIII-OUTLET SEPTUMOUTLET SEPTUM deficient supracristal,subpulmonary,infundibular or
conoseptalSEPTAL DEFICIFNCYSEPTAL DEFICIFNCY –AVseptal defect (AVcanal)
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CLINICAL FEATURESCLINICAL FEATURES
Race : no particular racial predilection Sex :no particular sex preference Age :infantsinfants– difficult in postnatal period,although ccf
during first 6mths is frequent,X-ray&ECG are normal. childrenchildren—after first year variable clinical picture
emerges.small VSD – asymptomatic large VSD – common symptoms -palpitation,dyspnoea on exertion,feeding
difficulties ,poor growth -frequent chest infections
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PHYSICAL FINDINGSPHYSICAL FINDINGS
• Pulse pressure is relatively wide• Precordium is hyperkinetic with a systolic thrill at LSB• S1&S2 are masked by a PSM at Lt.sternal border ,max. intensity of
the murmur is best heard at 3rd,4th&5th Lt interspace.Also well heard at the 2nd space but not conducted beyond apex
• Lt. 2nd space –widely split &variable accentuated P2• Delayed diastolic murmur at the apex &S3• Presence of mid-diastolic ,low pitched rumble at the apex is caused
by increased flow across the mitral valve &indicates Qp:Qs=2:1/greater
• Maladie de RogerMaladie de Roger –small VSD presenting in older children as a loud PSM w/o other significant hemodynamic changes
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INVESTIGATIONSINVESTIGATIONS ECHOCARDIOGRAPHYECHOCARDIOGRAPHY two-dimensional &doppler colour flow
• CHEST RADIOGRAPHYCHEST RADIOGRAPHY - normal - biventricular hypertrophy - pulmonary plethora
• ELECTROCARDIOGRAPHYELECTROCARDIOGRAPHY -smallVSD ~ normal tracing -mod.VSD ~ broad,notched P wave characteristic of Lt. Atrial
overload as well as LV overload,namely,deep Q waves & tall R waves in leads V5 and V6 and often AF
-large VSD ~RVH with rt. axis deviation. With further progression biventricular hypertrophy;P waves may be notched/peaked.
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Other investigationsOther investigations
CAT SCAN
(Computed Axial Tomography)
• MRI
• ULTRASOUND
• ANGIOGRAPHY
(cardiac catheterization and angiography)
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COMPLICATIONSCOMPLICATIONS
Congestive cardiac failure Infective endocarditis on rt.ventricular side Aortic insufficiency Complete heart block Delayed growth & development (FTT) in infancy Damage to electrical conduction system during
surgery(causing arrythmias) Pulmonary hypertension
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INTERVENTIONINTERVENTION
3 MAJOR TYPES SMALL (less than 3mm SMALL (less than 3mm
diameter)diameter) - hemodynamically
insignificant - b/w 80-85% of all VSDs - all close spontaneously * 50% by 2yrs * 90% by 6yrs * 10% during school yrs
- muscular close sooner than membranous
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MODERATE VSDsMODERATE VSDs * 3-5mm diameter * least common group of children(3-5%) * w/o evidence of ccf/ pulm.htn can be
followed until spontaneous closure occurs.• LARGE VSDs WITH NORMAL PVRLARGE VSDs WITH NORMAL PVR * 6-10mm in diameter * usually requires surgery otherwise… develop CCF & FTT by age of 3-6mths.Conservative treatment - treat CCF & prevent development of
pulm.vascular disease - prevention & treatment of infective
endocarditis
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INDICATIONS for SURGERYINDICATIONS for SURGERY VSDs at any age where clinical symptoms and
FTT cannot be controlled medically. Infants b/w 6-12mths of age with large defects
ass. with PH ,even if symptoms are controlled by medication.
Pt.s older than 24mths of age with Qp:Qs is greater than 2:1.
Pt.s with supracristal VSD of any size, because of high risk of development of AI.
CONTRAINDICATIONCONTRAINDICATION –severe pulmonary vascular disease.
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Surgical correction has to be done before irreversible damage to pulmonary vasculature occurs.
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Operative procedureOperative procedure Usually performed in second year.If symptoms
are not disabling ,procedure may be deffered to 4-6yrs.
Through a median sternotomy with the help of extracorporeal circulation,a longitudinal ventriculotomy is performed usually in the infundibular part of the rt.ventricle & near the ant.descending coronary artery.
Alternate approach is through the rt.atrium, particularly when PVR is increased .
Defect is usually closed with an oval patch of knitted dacron by mattress suture posteriorly and continous suture anteriorly using prolene.
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Much more to comeMuch more to come
Are we all still awake?
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