Ventricular Septal Defect Flashcards
________________________ is the most common congenital heart defect (CHD)
Ventricular Septal Defect (VSD)
VSD is defined as a condition where there is ____________________________. It can occur as an isolated lesion or alongside other CHDs
a hole in the septum separating the left and right ventricles
VSDs can be categorised in different ways, but the most applicable ones are by their ______ and their _______ in the interventricular septum.
size; location
Peri-membranous defects which occur in the (upper or lower?) , ________ portion of the ventricular septum, near the valves, are the (least or most ?)common VSDs, accounting for _____% of VSDs.
Muscular defects, where the opening is in the (upper or lower?), muscular section of the septum, account for _____%, with other rarer and more complex forms accounting for the other 10% of cases (5).
Upper; membranous
Most; 70
Lower; ; 20
Pathophysiology of VSD
Most patients with VSD experience symptoms primarily because of the ___________________________ . Since the pressure in the left ventricle is greater than in the right ventricle, the majority VSDs will be shunting left-to-right.
The ______ of the defect is the main determinant of the haemodynamic consequences of the VSD:
increased flow of blood through the pulmonary circulation
size
Pathophysiology of VSDs
Very small VSD, also called __________ VSD: The flow of blood through the VSD is (minimal or maximal?) , so there is no significant increase in pulmonary blood flow. These patients tend to be ___________________.
restrictive; minimal
asymptomatic
Pathophysiology of VSDs
Moderate sized VSD: The flow of blood through the VSD is great enough to cause a significant increase in blood flow through the pulmonary circulation. As the shunt is happening in _________, the extra volume of blood is pumped _________________, so there is no initial effect on the right ventricle.The _____ side of the heart though, is receiving a greater volume of blood, which can cause ___________ of the left atrium and ventricle.These patients are at risk of developing ______________ and ____________ .
Patients can progressively develop ________________ and the wall of the right ventricle can ___________ as it pumps against higher pulmonary pressures.
systole
directly to the pulmonary circulation
left; dilatation
congestive heart failure and arrhythmias
pulmonary hypertension; hypertrophy
Pathophysiology of VSDs
Large VSDs: A significant amount of blood is passing from the left to the right ventricle, and so these patients develop ____________ and severe ______________.Symptoms of cardiac failure are evident after the first ________ of life, when the initially high pulmonary artery pressures drop, allowing more blood to shunt through the defect and into the lungs and thus creating _____________.
early heart failure
pulmonary hypertension
weeks
pulmonary plethora
Eisenmenger’s Syndrome is a condition where _____________________ and is caused by a significant gradual increase in the ________________________.
It results in a ____________, with deoxygenated blood flowing from the right ventricle into the left ventricle and entering the systemic circulation. This causes decreased systemic oxygen saturation and these patients become cyanotic.
the pressure in the right ventricle exceeds that of the left ventricle
pulmonary vascular resistance
shunt reversal
Risk Factors
Maternal ___________
Maternal _________ infection during pregnancy
___________(__________ syndrome)
Uncontrolled maternal _______________ during pregnancy.
A family history of VSD is associated with increased risk of VSD.
Other congenital conditions have been shown to be related to the development of VSD.
_______ Syndrome (trisomy ____)
Trisomy ____ syndrome
Trisomy ____ syndrome
__________ Syndrome
Several medications are suspected teratogens, though evidence is often weak.
Diabetes Mellitus
Rubella; Alcohol (Foetal alcohol syndrome)
phenylketonuria (PKU)
Down’s; 21; 18; 13
Holt-Oram
Clinical Features
Small VSD
Typically, patients will have mild or no symptoms. Most commonly these infants are brought to medical attention because a ___________ is detected during a routine examination.
systolic murmur
Clinical features
Moderate VSD
Babies may have excessive ________, become easily __________, and have ________________. These may all be especially notable when feeding, though can be apparent at rest in more severe cases.
Symptoms are usually obvious by the age of ______________, as the pulmonary vascular resistance decreases causing an increase in left-to-right shunting.
sweating; fatigued
tachypnoea (rapid breathing)
2-3 months
Clinical features
Large VSD
Babies can demonstrate similar symptoms to _____________. The baby can present with shortness of breath, problems _______, ___________ issues regarding weight and height, and may have frequent __________________. In general, the larger the VSD, the sooner the symptoms are noted.
However, with large VSDs – especially if diagnosis and treatment are delayed – __________________ may develop which can lead to cyanosis.
Patients can demonstrate an intolerance to exercise, dizziness, chest pain, ankle swelling and a bluish complexion with clubbing of the fingers and toes. In severe cases, patients may cough up blood (haemoptysis).
congestive heart failure
feeding; developmental
chest infections
Eisenmenger’s Syndrome
Physical Examination
Inspection
General appearance:
Undernourished: A symptom of VSD is _______ during feeding which can cause the child to be undernourished.
Sweat on forehead: A sign of increased _____________ as a compensatory mechanism for decreased _________.
Increased work of breathing attributed to ____________.
Colour: With large VSDs, patients may become ________, developing a bluish complexion. A blue tinge around the lips can be misleading so it is important to check the _______,_________ and ________
fatigue; sympathetic activity; cardiac output
pulmonary congestion
cyanotic; tongue ; nail beds ; conjunctiva.
Clubbing:
Clubbing of the fingernails and toenails can be a sign of _____ standing _______________ that may be too mild to cause a bluish complexion. Note that other causes of clubbing include _____ disease, _________, subacute bacterial endocarditis as well as _____________ clubbing.
long; arterial desaturation
lung; liver cirrhosis
physiological familial
______________ is often the earliest sign of left sided heart failure.
Tachypnoea
Palpation
It is important to palpate the precordium and to check the peripheral pulses.
Pulse Rate: ________ in congestive heart failure
Precordial palpation: The area above the heart where the heartbeat is normally felt is moving too much (___________ precordium – caused by a _____________ in the left side of the heart)
Thrills: A thrill of maximal intensity in the _________________ border would be expected.
Raised; hyperactive
volume overload
lower left sternal
Auscultation
Systolic Murmurs:
Systolic murmurs occur between the S1 and S2 heart sounds.
Location: ______________
Quality: A uniform, ______ pitched sound, often described as a _______ sound.
The murmur is either holosystolic or early systolic:
Holosystolic (___________) murmur: Starts at S1 and __________________. This is the (most or least?) likely type of murmur to be heard with VSD.
Early systolic murmur: Starts at S1 and ________________________. It usually occurs when there is lower than normal pressure difference between the two sides of the defect.
Lower left sternal border;
high; blowing
Pansystolic; extends all the way to S2; most
ends in the middle or early systole
Auscultation
Diastolic murmur:
An __________ diastolic murmur may be heard with VSD.
Cause: Increased blood flow through the mitral valve causing a relative ____________
Location: The _________
Timing: Early to mid-diastole
Description: It starts with an abnormally _________. Though often referred to as an __________, it is said to sound more like a hum than a rumble.
apical mid
mitral stenosis
heart apex; loud S3
apical rumble
Differential Diagnoses of VSD
_______________ : Since a similar holosystolic murmur is heard in the same region as with VSD, an _____________ is required to differentiate between the two.
______________ : A characteristic finding here is an increase in the murmur intensity with inspiration (__________ sign).
____________ defect: The murmur is usually ______________________________ and is either mid or ejection systolic rather than holosystolic
Patent ductus arteriosus: Associated with a continuous systolic and diastolic murmur at the base of the heart.
Pulmonary stenosis: Ejection systolic murmur at the left upper parasternal border
Tetralogy of Fallot: Symptoms tend to be ________________________
Mitral regurgitation; echocardiogram
Tricuspid regurgitation; Carvalho’s
Atrial septal; higher up the left parasternal region
a lot more severe than with most VSDs.
Investigations
Bedside: ________
Bloods: ______ screen
Radiological:
_________
___________(gold standard?)
ECG
Septic
Chest X-Ray
Echocardiography
Medical Management of VSD
Increased ___________________
Diuretics: _____________ , To minimise _________ loss, _____________ can be added.
______________________ inhibitors
caloric density of feedings
Furosemide; potassium
Spironolactone
Angiotensin-Converting Enzyme (ACE)
In adults, the guidelines recommend that surgical closure of a VSD is indicated when there is a Qp/Qs (pulmonary-to-systemic blood flow ratio) of ______ or more (8)
2.0
However, the risk of developing Eisenmenger’s Syndrome is considered minimal if large VSDs are surgically closed in the first _____ years of life.
2
