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Echo Conference 5/11/11

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Ventricular Septal Defects ECHO CONFERENCE 5/11/11 DARRYN APPLETON Pregnancy and VSDs Pregnancy well tolerated in women with small to moderate sized VSDs as long as ... – PowerPoint PPT presentation

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Title: Echo Conference 5/11/11


1
Ventricular Septal Defects
  • Echo Conference 5/11/11
  • Darryn Appleton

2
Outline
  • Morphology, Types Pathophysiology
  • Natural History and Clinical Presentation
  • Some Echo examples
  • Clinical Scenarios and Recommendations
  • Interventions Indications, Surgery, Percutaneous
  • Pregnancy and Endocarditis Prophylaxis
  • Review Questions

3
Introduction
  • The most common form of CHD, accounting for up to
    20-40 of patients diagnosed with CHD
  • Impact may range from asymptomatic to pulmonary
    HTN, LV volume overload and RVH
  • Morphology 4 types
  • Membranous most common type in adults (80)
  • Muscular most common type in young children
  • Complete AV septal (endocardial cushion) defects
  • Supracristal (subarterial)

4
Morphology The Ventricular Septum
5
Morphology The Ventricular Septum
  • Membranous
  • Outflow
  • Trabecular septum
  • Inflow
  • Subarterial / Supracristal

6
VSD Types
7
VSD Types
8
VSD Types
9
Pathophysiology
  • Defect size is often compared to aortic annulus
  • Large gt 50 of annulus size
  • Medium 25-50 of annulus size
  • Small lt25 of annulus size

10
Pathophysiology
  • Restrictive VSD is typically small, such that a
    significant pressure gradient exists between the
    LV and RV (high velocity), with small shunt
    (Qp/Qs 1.4 1)
  • Moderately restrictive VSD ? moderate shunt
    (Qp/Qs 1.4 to 2.2 1)
  • Large / non-restrictive VSD ? large shunt (Qp/Qs
    gt 2.2 1)
  • Eisenmenger VSD ? irreversible pulmonary HTN and
    shunt may be zero or reversed (i.e. R?L)

11
Natural History
  • Restrictive typically does not have hemodynamic
    impact and may close spontaneously
  • Location Location Location Subaortic may result
    in progressive AI
  • Moderately restrictive does create LV overload
    and dysfunction along with variable increase in
    PVR
  • Large / non-restrictive LV volume overload
    earlier in life with progressive pulm HTN and
    ultimately Eisenmenger syndrome

12
Clinical Features
  • Peds
  • Murmur
  • Dyspnea, CHF, Failure to thrive
  • Adults
  • Asymptomatic murmur harsh, pansystolic, left
    sternal border
  • Mod restrictive dyspnea, a.fib, displaced apex,
    murmur, S3
  • Non-restrictive Eisenmenger VSD central
    cyanosis, clubbing, RV heave, loud P2

13
Echo Example 1
14
Echo Example 1
15
t
Outlet VSD Para long axis
16
Echo Example 2
17
Echo Example 2
18
Echo Example 2
19
Supracristal VSD, with pulm outflow tract
obstruction
20
Echo Example 3
21
Echo Example 3
22
Echo Example 3
23
Echo Example 3
24
Echo Example 3
25
Echo Example 3
  • Type
  • Size

Membranous
Restrictive
26
Echo Example 4
27
Echo Example 4
28
Echo Example 3
Type Size Shunt
Muscular
Large / Non-restrictive
  • R?L (inc RH pressures)
  • RV dilated
  • Eisenmengers

29
Clinical Scenarios Recommendations
  • Symptomatic young infant with Pulm HTN
  • Early surgery within 3 months.
  • Medical therapy with diuretics /- ACEI pre-op
  • Asymptomatic pt without Pulm HTN but with LV
    overload
  • Closure usually recommended to avoid late LV
    dysfunction
  • Asymptomatic pt, small VSD, no LV dilation
  • Conservative
  • Asymptomatic pt, small VSD but with AI/prolapse
  • Peri-membranous VSD with more than trivial AI
    should have surgery

30
Clinical Scenarios Recommendations
  • Eisenmenger Syndrome
  • Supportive
  • Bosentan (Endothelin receptor antagonist)
    improves functional capacity, QOL
  • Sildenafil

Penny DJ, Vick GW. Lancet 2011 377 1103-12
31
Interventions
  • Indications for Surgical Closure in adults
  • Evidence of LV volume overload (Class I if Qp/Qs
    gt2, Class IIa if Qp/Qs gt 1.5)
  • History of bacterial endocarditis (Class I)
  • Significant L?R shunt with PA pressure lt 2/3
    systemic and PVR is lt 2/3 SVR
  • Surgical Closure
  • Considered the first-line choice of therapy for
    those with indications
  • Usually involves direct patch closure w
    cardio-pulm bypass
  • Operative mortality lt 2 in most centers

32
Long Term Surgical Outcomes
  • Retrospective review of 46 pts with surgical VSD
    repair at Mayo Clinic

Mongeon et al. JACC Int 2010 3 290-7
33
Interventional Options
  • Percutaneous Device Closure
  • Muscular VSDs can typically be closed
    percutaneously
  • Class IIb recommendation in Guidelines (i.e.
    surgery still preferred)
  • No FDA approved devices for perimembranous VSDs,
    although there are specific devices for this
    purpose
  • Concern re proximity of defect to AV node and
    high risk of complete AV block requiring pacemaker

34
Pregnancy and VSDs
  • Pregnancy well tolerated in women with small to
    moderate sized VSDs as long as there is no
    pulmonary vascular involvement
  • Eisenmenger syndrome Pregnancy contraindicated
    due to exceptionally high risk of maternal and
    fetal death

35
Endocarditis Prophylaxis for VSD
  • Uncomplicated VSD no Abx for dental or other
    procedures required
  • Post repair
  • Abx for 6 months following surgical or
    percutaneous repair
  • Indefinite Abx if there is residual shunt
  • Risk of bacteremia from daily life usually
    exceeds that of procedure ? Abx for procedures
    only prevent small of cases
  • Focus should be on optimal dental hygiene for
    those with CHD

36
Question 1
  • An isolated VSD will generally cause enlargement
    of which chamber(s)
  • A Left atrium, left ventricle
  • B Right ventricle
  • C Right ventricle, pulmonary artery
  • D Aorta
  • E Right ventricle, right atrium

37
Question 1
  • An isolated VSD will generally cause enlargement
    of which chamber(s)
  • A Left atrium, left ventricle
  • B Right ventricle
  • C Right ventricle, pulmonary artery
  • D Aorta
  • E Right ventricle, right atrium

38
Question 2
39
Question 2
  • The defect shown on the previous slide is a
  • A Muscular VSD
  • B Sinus venosus VSD
  • C Perimembranous VSD
  • D Inlet VSD
  • E Supracristal VSD

40
Question 2
  • The defect shown on the previous slide is a
  • A Muscular VSD
  • B Sinus venosus VSD
  • C Perimembranous VSD
  • D Inlet VSD
  • E Supracristal VSD

41
Question 3
  • A common complication of this defect is
  • A Pulmonary valve endocarditis
  • B Aortic regurgitation
  • C Aortic dissection
  • D Tricuspid regurgitation
  • E Right ventricular enlargement

42
Question 3
  • A common complication of this defect is
  • A Pulmonary valve endocarditis
  • B Aortic regurgitation
  • C Aortic dissection
  • D Tricuspid regurgitation
  • E Right ventricular enlargement

43
Question 4
  • There is no diastolic flow in this perimembranous
    VSD
  • A True
  • B False

44
Question 4
  • There is no diastolic flow in this perimembranous
    VSD
  • A True
  • B False

45
Question 5
  • A restrictive VSD is a simple lesion with a good
    long term prognosis. However, complications can
    occur. All of the following are possible
    complications of a VSD except
  • A Endocarditis
  • B Aortic regurgitation
  • C Aortic valve prolapse
  • D Eisenmenger Syndrome
  • E Right sided volume overload

46
Question 5
  • A restrictive VSD is a simple lesion with a good
    long term prognosis. However, complications can
    occur. All of the following are possible
    complications of a VSD except
  • A Endocarditis
  • B Aortic regurgitation
  • C Aortic valve prolapse
  • D Eisenmenger Syndrome
  • E Right sided volume overload

47
Question 6
48
Question 6
  • The pulmonary artery systolic pressure in this
    patient with a VSD is
  • A Normal
  • B Moderately elevated
  • C Systemic / Supra-systemic

49
Question 6
  • The pulmonary artery systolic pressure in this
    patient with a VSD is
  • A Normal
  • B Moderately elevated
  • C Systemic / Supra-systemic

50
Question 7
  • A patient with a VSD undergoes TTE. BP measured
    at the time of the study is 125/75 (right arm),
    MAP 92. CW doppler across the VSD gives a peak
    velocity of 5 m/s. Assuming RA pressure of 5,
    what is the estimated PASP?
  • A 20mmHg
  • B 25 mmHg
  • C 30 mmHg
  • D 72 mmHg
  • E 105 mmHg

51
Question 7
  • A patient with a VSD undergoes TTE. BP measured
    at the time of the study is 125/75 (right arm),
    MAP 92. CW doppler across the VSD gives a peak
    velocity of 5 m/s. Assuming RA pressure of 5,
    what is the estimated PASP?
  • A 20mmHg
  • B 25 mmHg
  • C 30 mmHg
  • D 72 mmHg
  • E 105 mmHg

52
VSD Hemodynamics
  • Peak gradient 4 x v2 (Simplied Bernoulli
    equation)
  • VSD gradient LV systolic pressure RV systolic
    pressure
  • RVSP LVSP - VSD gradient
  • RVSP cuff systolic BP - VSD gradient (or 4 x
    v2)
  • Assuming no aortic outflow tract obstruction
  • PASP RVSP
  • Assuming no pulmonary outflow tract obstruction
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