CMT06209: Apprenticeship in

Paediatrics and Child Health

Session 2 VENTRICULAR
SEPTAL DEFECT (VSD)
Total Session time 120 minutes
 Learning Objectives
• By the end of this session, a student is
expected to learn the following;
– Explain aetiology/risk factors of Ventricular
Septal Defect
– Outline epidemiology of Ventricular Septal
Defect
– Explain clinical features of Ventricular Septal
Defect
– Establish diagnosis/ provisional and differential
diagnosis of Ventricular Septal Defect
 Learning Objectives cont…
– Provide pre-referral treatment of Ventricular
Septal Defect
– Provide appropriate supportive care for
Ventricular Septal Defect
– Provide follow-up services of Ventricular
Septal Defect
Ventricular Septal Defect (VSD)
• VSD – is an abnormal opening in the
ventricular septum, which allows free
communication between the right and left
ventricles
• Most common of all CHD (30%-60%)
• 85% close spontaneously
• Follows incomplete development during
early utero life
Types of Ventricular Septal Defect
Four (4) Types:
• Perimembranous/membranous = commonest

• Infundibular (subpulmonary or supracristal

VSD) – involves the RV outflow tract

• Muscular VSD – can be single or multiple

• AVSD – inlet VSD, almost always involves

AV valvular abnormalities
 Pathophysiology of VSD
• During systole, the rise in left ventricular
pressure (LVP) causes leaking of blood from LV
to RV which will re-enters the LV from the
pulmonary circulation
• Two net Effects:
– circuitous refluxing causes volume overload in
LV
– leakage of blood to the RV increases the
volume and pressure in RV causing
pulmonary HT and it’s associated symptoms
(including hypertrophy of the LA & LV)
Pathophysiology of VSD cont…
Eisenmenger’s syndrome:
• Initially, there is Left to Right shunt of blood
caused by high blood pressure in the left
ventrical through (ventricular) septal defect
• Large defect causes increased pulmonary flow
to the pulmonary vasculature
• Pulmonary hypertension (HT) develops
• Later, reversal of the shunt from left-to-right to
right-to-left occurs
• Cyanosis and other symptoms of pulmonary HT
sets in
 Clinical Features of VSD
• Small - moderate VSD: (3-6mm)
– usually asymptomatic
– 50% will close spontaneously by age of
2yrs

• Large VSD:
– almost always have symptoms
– require surgical repair
 Clinical Features of VSD cont…
• Symptoms develop between 1 – 6 months
• In infant with a large VSD
– sweaty and tachypnoiec (breathe faster)
with feeds
– exercise intolerance (CHF)
– failure to thrive

• Recurrent respiratory infections

Clinical Features of VSD cont…
• Initially heart sounds are normal
• Tachycardia; gallop rhythm
• Pansystolic murmur, depending upon the size of
the defect
• +/- palpable thrill (palpable turbulence of blood
flow), hyperactive precordium
• Parasternal heave in larger VSD
• Displaced apex beat over time as the heart
enlarges
• Later, cyanosis ensues as a result of shunt
reversal
 Investigations
• Chest x-ray - CXR
– cardiomegally, increased pulmonary markings
• ECG
– chamber hypertrophy (LV, bi-ventricular, or LAH)
• CXR&ECG are normal with small VSD
• ECHO
– defect location, size, RVP
• Other investigations are supportive such
blood tests in recurrent chest infections
 Ventricular Septal Defect
Treatment
• Small VSD
– no surgical intervention; no physical restrictions
– reassurance and periodic follow-up
– endocarditis prophylaxis

• Symptomatic VSD
– initially medical treatment to be provided before
referral include treatment of chest infections and anti-
failure drugs such as afterload reducers & diuretics
– Refer for surgical closure
 Supportive Care
• Mainly involves
– management of accompanying conditions
such malnutrition with standard therapy
– counselling to parents and/or care-takers on
the condition and what to be done
 Key Points
• Ventricular Septal Defect (VSD) is an
abnormal opening in the ventricular
septum developing during early utero-life
• VSD is commonest of all CHDs
• Four types VSD exist,
perimembranous/membranous,
infundibular (subpulmonary or supracristal
VSD), muscular VSD and AVSD – inlet
VSD
 Key Points cont…
• Small - moderate VSD are usually asymptomatic
and half of cases closes spontaneously by age
of 2yrs
• Large VSD are almost always have symptomatic
and requires medical and/or surgical repair
 Evaluation
• What are features of Ventricular Septal
Defect?
• What are the diagnostic investigations for
Ventricular Septal Defect?