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Ventricular Septal defect (VSD)

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Small VSD's may produce loud murmurs and large VSD's may produce no murmur at all but will cause heart failure usually at 6+ weeks. Many smaller VSD's close without any treatment

About

Abnormal shunt between LV and RV.
Seen in 2/1000 live births so commonest congenital heart disease

Aetiology

Size of defect and pulmonary pressures determine clinical picture
Increased pulmonary flow can result in pulmonary hypertension which then reduces flow
Can lead to Eisenmenger's syndrome and reversal of flow will lead to cyanosis

Anatomical Types

Type of VSD	Description	Comments
Perimembranous VSD	The most common type, located in the membranous portion of the ventricular septum, near the tricuspid and aortic valves.	Can vary in size and often associated with aortic valve prolapse or insufficiency. It may close spontaneously, especially in smaller defects.
Muscular VSD	Occurs in the muscular portion of the septum, lower in the ventricular septum, away from the valves.	Often referred to as "Swiss cheese" VSD when multiple small defects are present. These defects have a high chance of spontaneous closure.
Inlet (Atrioventricular Canal) VSD	Located near the tricuspid and mitral valves, in the area where the blood enters the ventricles from the atria.	Commonly associated with atrioventricular septal defects (AVSD) and Down syndrome. Surgical intervention is often required.
Outlet (Supracristal or Subarterial) VSD	Located near the outflow tracts of the right and left ventricles, beneath the pulmonary and aortic valves.	Less common, more frequent in Asian populations. Associated with aortic valve prolapse, which may necessitate early surgical repair.
Gerbode VSD	Rare type of VSD that involves a direct communication between the left ventricle and the right atrium.	This type of defect is unusual and often requires surgical correction due to the significant left-to-right shunt it causes.

Clinical

Loud, harsh pan systolic murmur/thrill at the lower left sternal border
Hyperdynamic LV apex beat, pulmonary oedema
Poor weight gain, fatigue after feeding. Look for signs of endocarditis
Eisenmenger's syndrome - murmur reduces, RV failure
High risk of endocarditis so be vigilant
RV hypertrophy with lift and Volume overloaded LV,
Small VSDs create loud murmurs and Large VSDs create soft murmurs

Investigations

Bloods: Raised WCC/ESR/CRP may suggest endocarditis. U&E and LFTS: usually normal
CXR: normal with small VSD but cardiomegaly and enlarged Pulmonary arteries and increased vascular markings and possibly oedema
ECG: normal if small otherwise RVH and LVH
Echocardiogram: can anatomically place VSD and estimate pulmonary artery pressures

Management

Management Option	Description	Comments
Observation	Close Monitoring of the VSD without immediate intervention. Small defects are likely to close spontaneously without intervention.	Small muscular VSDs, particularly in infants, as these defects frequently close on their own.
Medications	Use of drugs such as IV/PO diuretics, ACEi, and digoxin to manage fluid overload/heart failure.	Can alleviate symptoms, prior to definitive surgery. Use when surgery delayed or not immediately necessary.
Surgical Repair	Open-heart surgery to close the VSD using a patch or sutures.	Indicated for large defects causing significant symptoms, failure to thrive, or increased pulmonary blood flow. Surgery is often performed in early childhood.
Transcatheter Device Closure	A minimally invasive procedure where a device is inserted through a catheter to close the VSD.	Typically used for muscular VSDs or residual VSDs after surgery. It’s less invasive than open-heart surgery and involves a shorter recovery time.
Endocarditis Prophylaxis	Antibiotic therapy to prevent infective endocarditis, particularly in patients with certain types of VSD or after surgical repair.	Recommended for individuals with VSD who have a history of endocarditis or those who have undergone VSD repair with residual defects.
Long-term Follow-up	Regular cardiac evaluations to monitor for complications such as residual defects, arrhythmias, or pulmonary hypertension.	Essential for all patients with a history of VSD, regardless of whether they have undergone surgical or transcatheter repair.

Complications

Endocarditis, Heart failure, Arrhythmias

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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