1. Congenital heart disease
Dr. aso faeq salih
Pediatric cadiologist

2. Ventricular Septal Defect ( VSD )

3. Most common cardiac malformation  25-30 %
Types of VSD :
According to position  perimembranous , inlet , muscular .
According to size  small , medium , large .
Membranous :
most common , are usually single ,( called peri membranous )
may extend into adjacent muscle

4. Muscular :
mid portion of septum to the apex .
Single or multiple (Swiss cheese septum )
Inlet :
At level of both Av valve s

5. Size of defect : Small (restrictive ) :
Trivial L  R shunt . (LV pressure > RV )
Normal pulmonary arterial &RV pressure .
Normal cardiac chambers .

6. Large (non restrictive ) :
> aortic annulus
RV, LV pressure equalizes .
Direction & magnitude of shunt determined by ratio of pulmonary to systemic vascular resistance .
RV , pulmonary arterial hypertension .
Main pulmonary artery , LA , LV are enlarged
Medium will be in between

7. Pathophysiology :

8. Clinical features :
Varies according to : size of defect , pulmonary blood flow & pressure .
Small VSD :
Most often asymptomatic .
Loud , harsh , blowing , holosystolic murmur heard best over LLSB frequently accompanied by thrill .

9. Large VSD : Physical signs :
Dyspnea , feeding difficulties , poor growth , profuse perspiration , recurrent chest infection & cardiac failure in early infancy .
Cyanosis usually absent , duskiness noted during crying or infection .
Physical signs :
Prominent L precordium , palpable para sternal lift .
Lateral displacement of apex beet , apical thrust .
Holosystolic murmur ( less harsh , more blowing ).
Pulmonary component of S2 may be increased  pulmonary hypertension

10. Investigations : CXR : ECG:
Small VSD : normal or minimal cardiomegaly .
borderline increase in pul. Vasculature .
Large VSD : gross cardiomegaly ( RV , LV, LA PA ).
prominent pulmonary vascularity .
ECG:
Small VSD : normal or may suggest LV hypertrophy
Large VSD: biventricular hypertrophy
P- wave notched or peaked .

11. Echocardiography :
Cardiac catheterization

12. Treatment :
Small VSD:
Reassurance & encourage to live normal life with no restriction of activities .
Protection against infective endocarditis .
Regular follow – up

13. Large VSD : Aim of treatment : Control the symptoms of H.F .
Prevent the development of pulmonary vascular disease .
Surgical closure of defect : Indications :
Patient at any age with large defect in whom clinical symptoms , FTT cannot be controlled medically .
Supracristal VSD .
VSD complicated with AR or subvalvular PS

14. Complication of surgery :
Residual defect .
Heart block .

15. Prognosis & complications :
Small VSD :
Spontaneous closure : 30 – 50 % most often during first 2 years of live ( small muscular are > likely to close ( up to 80 % ) than membranous (up to 35 % ) .
Most often asymptomatic .
Infective endocarditis .

16. Moderate – Large VSD :
Early & successful therapy may become smaller & up to 8 % may close completely .
Repeated episodes of chest infection .
H.F & FTT .
Pulmonary HT & evidence of pulmonary vascular disease .
Eisen menger complex .
Aortic valve regurgitation
Acquired infundibular pulmonary stenos is .

17. Patent Ductus Arteriosus ( PDA)

18. 6 – 8 % of CHD , F:M  2 : 1 Ductus Arteriosus :
Ass. With maternal rubella infection in early pregnancy .
Common problem in premature infants .
Ductus Arteriosus :
Fetal life , patency of Ductus is maintained by :
Relaxant effect of low O2 tension .
Prosta glandines (E2) .

19. In full term neonates , once Po2 passing through Ductus reaches 50 mmHg Ductal wall constricts . Functional closure of Ductus  10 – 15 hrs. in normal neonate , anatomical occlusion 4 m of age Ligamentum arteriosum

20. Pathophysiology :

21. Types &clinical manifestations :
Small PDA :
Usually asymptomatic .
Normal cardiac size .
Pressure within PA , RA & RV are normal .

22. Large PDA : PA pressure may be elevated to a systemic pressure .
Risk of pulmonary vascular disease .
Often symptomatic ( HF & growth retardation ).
Bounding peripheral pulsations .
Wide pulse pressure .
Moderate – gross cardiomegaly .
heaving apical impulse.
Thrill (systolic ) max. in 2nd L ICS +/_ radiation .
Machinery continuous murmur max. in 2nd L ICS .

23. Investigations : CXR : Small PDA : normal .
Large PDA : moderate – gross cardiomegaly
( LV , LA ).
Prominent intra pul. Vascular marking .
normal or prominent aortic knob .
ECG : Small  normal.
Large  LV or biventricular hypertrophy.

24. Echocardiography :
Cardiac Catheterization :

25. Prognosis & complications :
Small PDA :
May live a normal span with a few or no symptoms .
Spontaneous closure after infancy is extremely rare.
Infective endocarditis .

26. Large PDA : HF in early infancy , FTT . Infective endocarditis .
Pulmonary or systemic emboli .

27. Treatment :
Surgery :
Ligation & division of Ductus , preferably before 1st year of live .
Trans catheter closure of defect.