Presentation on theme: "VENTRICULAR SEPTAL DEFECT (VSD)"— Presentation transcript:
1VENTRICULAR SEPTAL DEFECT (VSD) It is a hole on interventricular septum Congenital or acquired
2VENTRİKÜLER SEPTAL DEFEKT (VSD) CongenitalAcquiredIsolated VSD can be seen in nearly 2 per live births.It is the most frequent congenital cardiac anomaly.can be associated with other anomalies.It is mostly seen as a complication of acute myocardial infaction.Rarely trauma is a cause .
10CLASS ACCORDING TO SIZE VSD büyüklükleri; aort orifis çapına göre değerlendirilebildiği gibiVSD rezistans indekslerine (Rİ) göre de değerlendirilebilir.VSD Rİ = LVP - RVP x m2Qp-QsLVP= Sol ventrikül basıncı;RVP= Sağ ventrikül basıncı;Qp= Pulmoner kan akımı;Qs= Sistemik kan akımı;m2= Vücut alanı
11VSD Large VSD Moderate VSD VSD diameter < Aort diameter RVP=1/2 LVP VSD diameter ≥ Aortic diameterVSD Rİ < 20 Ü/m2Resistance to flow is smallRVP = LVPQp/Qs ratio depends on degree of pulmonary vascular resistance (PVR).VSD diameter < Aort diameterRVP=1/2 LVPQp/Qs≥2
12VSDSmall VSDVSD has not enough space to increase the right ventricular sistolic pressure.VSD Rİ>20Ü/m²Qp/Qs<1.75
13Patients with large VSD and increased Qp/Qs Weak peripheral pulses Symptoms and signsPatients with large VSD and increased Qp/QsWeak peripheral pulsesTachypnea, subcostal drawings, profuse sweatingHepatomegaly, high jugular venous pressure,Difficulty in feeding, growth retardation
14Large VSD and light PVRThere is a strong pansystolic (holosystolic) murmur or thrill on the left parasternal region over the 3th ,4th intercostal space ( subarterial VSD on 2nd, 3th ICS),Apical diastolic murmur because of increased blood flow passing throughout th mitral valve.S2 is strong and splitted due to increased pulmonary flow.
15Large VSD and high PVRLeft to right shunt decreases and becomes bidirectional.Hyperactivity of the heart and cardiomegaly decrease.Pansytolic murmur change in character, becomes short and soft.Apical diastolic murmur is no more heard.S2 is forcefull.The patient becomes cyanotic If PVR>SVR. (Eisenmenger sendrome)
16CHEST X-RAYLarge VSD and light PVRLarge VSD and high PVR
17Patients with Moderate size VSD Pansystolic murmurLight – moderate left and right ventricular enlargement.
18small VSDThere is harsh pansystolic murmur due to small VSD and shunt.EKG ve Chest X ray are normal.
19Echocardiography:2 Dimensional, colour Doppler ECHOGive us incredible information about the situation and size of the VSDQP/QS can be calculated.Associated anomalies like Aortic coarctation and PDA .
20HEART CATHETERIZATION To measure Pulmonary artery pressure,Left to right shunt and PVRTo define the place, number and size of the VSDTo show definitely the associatied anomalies.
22SPONTANOUS CLOSURE Less chance to close More chance to close PerimembranousJuxta aorticInlet septalJuxta-tricuspidMuscular (outlet)
23COMPLICATIONS Pulmonary Vascular disease Large VSD can have serious pulmonary resistance (Rp) in first 2 years of life
24Pulmonary Vascular disease (Heath Edwards Classification) Grade 1: Medial hyperthrophy.Grade 2: Medial hyperthrophy and intimal cellular proliferationGrade 3: Medial hyperthrophy and intimal fibrosis early generalized vascular dilatationGrade 4: Generalized vascular dilatation, vascular oclusions due to intimal fibrosis, plexiform lesions.Grade 5: Cavernous ve angiomatoid lesions.Grade 6: Necrotizing arteritis.
25Infective Endocarditis It is seen % of patient per yearMore often small and moderate VSDsRight sided vegetations (Tricuspid kapak)Lung infectionsAortic insufficiencyIn the first decade % .Especially subarterial VSD
26Early Death 9 % of the patient with large VSD die within the 1st year. PDA, Coarctation, large ASDRecurrent lung infections (Viral).Pulmonary edema (heart failure).After the first decade Eisenmenger complications (Hemoptisis, polycytemia, cerebral emboli, abscesses, right heart failure)50% of patients die before 35 years of age.
27Pulmonary Vascular Resistance < 4 ünite m2 Normal< 5 ünite m mildly elevated< 8 ünite m moderately elevated> 8 ünite m severely elevated
28INDICATIONS FOR OPERATION Large VSDEvery patient with intractable heart failure under medical treatment can be operated before 12 months.(Swiss cheese – Pulmonary banding)If there is growth failure or Rp >8ü m2 at 6 month, the operation should be performed.( If Rp < 4ü m2 , the operation can be deferred untill 12 month.)After infancy Rp is truely and precisely measured. If Rp < 8ü m patient can be operated, If Rp >8ü m2 , after isoproteronol perfusion remeasurement should be made If Rp ≤ 7ü m2 patient can be operated,
29INDICATIONS FOR OPERATION Moderate VSDIf Ppa mmHg and Qp/Qs is about 3 Rp is rarely elevates and we can wait for operation untill 5 years of age.Small VSDİnfective endocarditis, ventrikül dysfunction is rarely seen (After 10 years of age)
30SURGICAL TREATMENT Pulmonary banding 1-Swiss cheese septum with intractable heart failureComplicationsHospital mortality is highPulmonary stenosis, migration
31PATCH CLOSUREPerikardial, Dacron and PTFE patches can be used for closure.Interrupted suture (Teflon pledgeted single) or continuous suture can be used.From the right atrium Perimembranous.From the right ventricle----- subarterial(Ventricular scar can cause RBBB, Arythmia yüksek)