Ventricular septal defect

Moderator – Dr BhallaPresentor – Dr Priya

www.anaesthesia.co.in

anaesthesia.co.in@gmail.com

Harneet 8m male child Resident of Ludhiana Informant : mother

Difficulty in feeding × 7 m Increased respiratory rate × 7m

Chief complaints

H /O sweating while feeding , frequent interruption while feeding

H/O fast breathing with chest retractions H/O visible cardiac pulsation H/O poor weight gain

HOPI :

No H/O bluish discolouration while crying No H/O abdominal distention ↓urine output swelling of face and feet No H/O fever with spots over body

No history of any other illness in past Family history : first child , no similar

complaints Antenatal history : Regular follow up No intake of drugs , no H/O fever with rash USG normal

Past history :

Birth history : full term vaginal delivery at hospital

Cried immediately after birth Developmental history : Can sit without support and hold head Immunization history : Adequately immunized for age

Treatment history : Furosemide + spironolactone and digoxin

Conscious lying on bed Pallor – absent No cyanosis ,ikterus , clubbing or edema VITALS: PR :120 /min regular rhythm ,normal

volume ,no delay BP: 86/ 50 mm hg right arm supine RR : 48/min subcostal retractions present

General physical examination :

Temp : afebrile to touch Height : 64 cm Weight : 6.2kg Anterior fontanalle : not depressed Venous access : adequate No other visible malformations

Systemic Examination :- Cardiovascular system : Inspection :- precordial bulge - present visible pulsation +

no scar mark abnormality of skeletal structure.

Palpation :- Apex beat – left 5th ICS in MCL

palpable thrill. parasternal lift.

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Auscultation :- S1 & S2 audible S2 accentuated & split over pulmonary area. Pan-systolic murmur at apex & LLSB.

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Inspection : no visible chest wall deformity No visible pulsation seen Auscultation: B/L vesicular air sounds +, no

added sounds

Central nervous system :-conscious, apathetic no sensory or motor deficit reflexes normal.

Respiratory system :

Provisional diagnosis :-Acyanotic congenital heart disease with left

to right shunt without CHF or infective endocarditis

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Hb – 11.2 TLC – 9600 Na /K – 146/ 4.6 CXR - cardiomegaly , ↑ pulmonary

vascularity Echo : LA + LV enlarged , RA/ RV normal , 8

mm mid muscular VSD , mild MR

Investigations:

CongenitalIncidence of CHD :8 / 1000 live birth

Cyanotic: 22%

Acyanotic: 68%◦ VSD 25%◦ ASD 6%◦ PDA 6%◦ PS 5%◦ AS 5%

Prevalence

Most common CHD 2.6 to 5.7 /1000 live birth 10 % of adult CHD TYPES :-1. Subpulmonary (5-7 % )- with AV insufficiency2. Perimembranous (80 %)-with tricuspid valve

abnormality3. A-V canal (5-8%) 4. Muscular (5 -20 % )- multiple defect

Restrictive , non- restrictive Small, medium, large (in relation to aortic root )

VSD

ANATOMY

Extra cardiac malformation in 20-45 %

- Trisomy 21,18,13 - CHARGE syndrome - Fetal hydantion syndrome - Fetal alcohol syndrome - Fetal valproate syndrome - Apert syndrome

Syndrome associated with VSD

Severity of VSD :–

- loud P2, parasternal lift/heave - duration of murmur

- diastolic murmur at mitral area

- features of CCF

LARGE L- R SHUNT

↑ PVR

↑ LA SIZE↑LA PRESSURE

INTERSTITIAL AND ALVEOLAR EDEMA

↑ PA FLOW↑PA PRESSURE

ENLARGEMENT OF VESSELS

BRONCHIAL HYPERTROPHY

AIRWAY OBSTRUCTION

↑ AIRWAY RESISTANCE↓ PULMONARY COMPLIANCE

INCREASED WORK OF BREATHINGGAS TRAPPING, ATELECTASIS, INFECTION

Spontaneous closure of defects less than 5mm before 5 yrs of age (40-50%).

Natural course depends on – size, change in PVR, age

Large defects – CHF in infancy (2-6 wks), when PVR falls

Tachypnea, Distress, Sweating while feeding, Failure to thrive

CHF- apathetic, no movement, weak cry, diaphoretic, hepatomegaly

Indications for surgical closure- >6.5 mm, Qp:Qs ratio >2

NATURAL HISTORY

Shunt Gradient ↑ PVR RVP RVH LVH Murmur

Small L – R High -- N No Yes PSM

Medium L-R 20mm Hg

± Mild ↑ Mild Yes PSM

Large L-RR-L

None + ↑ Yes Yes Decreased

Large with PVR

R-L None + Yes No None

Features of VSD based on size

Preload

HR Contractility

PVR SVR

VSD (L→R) unrepaire

d

↑ N N ↑ ↓

VSD (L→R) repaired

↑ N N N N

VSD (R→L) ↑ N N ↓ ↑

Cardiac Grid