acyanotic congenital heart disease - vsd - dr. gunasekaran

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

DISEASES OF THE CARDIOVASCULAR SYSTEM

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

Outlet (infundibular)(Supra cristal)

Membranous (80%)

Muscular(5-20%)

Inlet

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

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

RARVPV PALungsPVLAMVLVAortaOther 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?

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 ???

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:

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

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)

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

Examination of heartPalpation:

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

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

Examination of heart -AuscultationHeart 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

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 LR shunt)

Eisenmenger’s syndrome

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:

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

ComplicationsCongestive 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

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

ComplicationsPulmonary 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)

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

ComplicationsEisenmenger’s syndrome

In LR shunt; shunt reversal severe PHT & cyanosis

Can occur in all LR (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 +

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

Differential diagnosisTricuspid Regurgitation:

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)

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:

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD

ManagementMedical:

Anemia correction

Proper nutrition (feed frequently)

Dental Hygiene

Infective Endocarditis Prophylaxis

Treatment for Cardiac failure

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 (LR)

CCF

PVR

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 (LR)- Small (PBF:SBF <1.5:1)

CCF-Absent

PVR Normal

No need for Surgery; Only life-long IE Prophylaxis

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 (LR)- large (PBF:SBF >2:1)

CCF+ not responding to medical management

PVR slightly increased

Outlet defects- associated with aortic cusp prolapse

Surgery is indicated

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

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

Dr. D. Gunasekaran D, MD., Dept., of Paediatrics, MGMCRI.

Acyanotic Congenital Heart Disease - VSD