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Ventricular Septal Defect

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Definition: interventricular septal communication (IVS) defined by its location. The IVS can be divided into a muscular and membranous portion, hence perimembranous VSD (80%) or muscular VSD (inlet/trabecular/outlet = infundibular region).  It is the most common type of CHD.

Incidence: 1.7-53:1000 of all live births.

Prevalence: 20% as a single lesion, 50% as part of lesion in CHD.


Physiology:

Depends on the size, PVR, RVP and LVP

  • in neonates with increased PVR there is minimal shunting
  • where there is a drop in PVR and and therefore less restrictive, there is a left to right shunt leading to volume load in the LA and LV.  This can lead to CCF and, if long standing, Eisenmenger syndrome

Diagnosis:

  • Clinical examination: auscultation – holosystolic murmur; cyanosis; and clubbing in Eisenmenger syndrome
  • ECG: LVH
  • CXR: increased pulmonary blood blow (in Eisenmenger there is reduced PBF)
  • ECHO: for size, location, shunt, haemodynamic evaluation
  • MRI: limited usefulness
  • Cardiac catheterization: PVR, response to pulmonary vasodilators, Qp:Qs

Preoperative management:

Treat CCF: CPAP/IPPV if required; digoxin; frusemide (1mg/kg up to QID); spironolactone (1mg/kg BD).

Aim for an afterload reduction:milrinone (0.25-0.5 mcg/kg/min) or captopril (0.1-2 mg/kg TDS).


Preoperative preparation:

ECG, CXR, CUS, FBE, clotting, UEC, PRBC (4), FFP (2), platelets (2), cryoprecipitate (2). methylprednisolone 10mg/kg 12hrs and 6hrs pre surgery in neonates.


Surgery:

Pulmonary artery banding for protection of pulmonary circulation in neonates with multiple VSDs and CCF

In children >3 months (Qp:Qs >1.5:1), surgical closure via transatrial approach, sometimes by right ventriculotomy, and rarely by left apical ventriculotomy. Catheter closure by amplatzer device. Heart-lung transplantation in Eisenmenger syndrome.


Postoperative management:

  • Inotropes: milrinone plus dopamine or adrenaline (plus noradrenaline). Aim for MAP >40 mmHg in neonates.
  • Haemodynamics: age adjusted (in neonates: SBP >60 mmHg, MAP >40 mmHg, CVP 8-12 mmHg).
  • Respiratory: normoxaemia, normocapnea.
  • Fluid restriction: 1ml/kg/hr, early feeds.
  • Continue preoperative diuretic therapy.
  • Haemostasis.
  • If catheter closure: aspirin 5mg/kg OD once feeds tolerated.

Specific problems:


Outcome:

Average ICU stay: 2 days.

Mortality: <1% in isolated VSD, but up 5-10% in multiple defects.

Residual shunts: 30% after surgical closure, majority close spontaneously.


References:

[1] Br Heart J. 1980 Mar;43(3):332-43: Soto et al: Classification of ventricular septal defects

[2] Circulation. 2006 Nov 14;114(20):2190-7: Minette et al: Ventricular septal defects

[3] Cardiol Young. 2007 Jun;17(3):243-53: Butera et al: Percutaneous closure of ventricular septal defects


 All Marc’s PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or AndroidA list of contributors can be seen here.

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