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TYPE
Conoventricular VSD
Perimembranous
VSD
Inlet VSD
Muscular VSD
VSD
SMALL VSD
COMPLICATION
• Aortic
regurgitation
• IE
• Eisenmenger’s
syndrome
• Pulmonary
hypertension
A L to R shunt at the ventricular level has 3
hemodynamic consequences:
1. increase volume RV→increase pulmonary
flow→pulmonary hypertension→increase RV
pressure→R to L shunt→ increase LV volume
load→ LV dilatation and then hypertrophy→
increase pulmonary venous pressure→raises
pulmonary capillary pressure→increase
pulmonary interstitial fluid→pulmonary edema
2. excessive pulmonary blood flow
3. reduced systemic cardiac output
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Asymptomatic.
Loud pansystolic
murmur at LLSE
Quiet pulmonary
second sound (P2).
LARGE VSD
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Heart failure with breathlessness and FTT after 1
week old
Recurrent chest infections.
Tachypnoea, tachycardia and enlarged liver from
heart failure
Active precordium
Soft pansystolic murmur or no murmur
Apical mid-diastolic murmur (from increased flow
across the mitral valve after the blood has
circulated through the lungs)
Loud pulmonary second sound (P2)
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Normal CXR
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Cardiomegaly
Enlarged pulmonary arteries
Increased pulmonary vascular markings
Pulmonary oedema
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Normal ECG
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Biventricular hypertrophy by 2 months of age.
•
Close
spontaneousely
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-
Diuretics, captopril, calories
Surgery at 3–6 months old
Cardiac cathetherization
Pulmonary artery banding
Atrial Septal Defect (ASD)
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Accounts for 10% of all congenital defects.
Females > males (2:1)
Left to right shunt occurs between two low-pressure heart chambers, majority of cases
are asymptomatic during childhood.  usually suspected because of incidental heart
murmur.
Types:
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Ostium secundum defect (most common)
Ostium primum defect – part of AVSD spectrum.
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SMALL ASD
Asymptomatic
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Normal CXR
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Normal ECG
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Partial right bundle branch block, RV
hypertrophy pattern.
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Do not need specific treatment
May close spontaneously during early
childhood
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+ right heart dilatation, require elective
closure.
Secundum defects can be closed by
percutaneous interventional
technique.
Defects other than secundum and
very large secundum defects need to
closed surgically.
Closure of ASD is contraindicated if
there is significant pulmonary
hypertension.
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LARGE ASD
Parasternal heave, wide and fixed
splitting of the S2, ejection systolic
murmur.
Mild cardiomegaly, increased
pulmonary vascular marking
Patent Ductus Arteriosus (PDA)
Diagnosis
Risk factors for delayed closure of the PDA:
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Hypoxia,
Acidosis,
Immaturity
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Echocardiographic visualization of a PDA with Doppler flow imaging that demonstrates
left-to-right or bidirectional shunting.
↑ pulmonary pressure 2nd to vasoconstriction
Systemic hypotension
Local release of prostaglandins
Clinical Features
Small PDA
Large PDA
• Asymptomatic
• Heart failure symptoms
• Normal peripheral • Retardation of physical growth
pulses
• Bounding peripheral arterial pulses
• Wide pulse pressure
• Enlarged heart
• Continuous murmur, thrill at 2nd left intercostal space
• Functional closure of the ductus normally occurs soon after
birth, within the 1st wk of life. If the ductus remains patent
when pulmonary vascular resistance falls, aortic blood
then is shunted left to right into the pulmonary artery.
• Female predominance 2 : 1.
• Associated with maternal rubella infection during early
pregnancy.
• Premature infants - the smooth muscle in the wall of the
preterm ductus is less responsive to high PO2 and less
likely to constrict after birth
Investigations
Chest Radiograph
• Prominent pulmonary
artery
• ↑ pulmonary
vascular markings
• Cardiomegaly
ECG
• Right ventricular
hypertrophy
Echocardiography
• Evaluates heart
structure & function
• Assess blood flow
pattern
• Estimate PDA size
Cardiac Catheterization
• Haemodynamic
measurements.
• Visualization of duct injection of contrast
medium
Complications
• Infective
endarteritis
• Pulmonary or
systemic emboli
• Paradoxical
emboli.
• Aneurysmal dilation
of the pulmonary
artery or the ductus
• Pulmonary
hypertension in
large PDA
Management – aim for closure of the PDA
Conservative
Operative
• COX inhibitors – Inhibit prostaglandin • After 14 days of life, proceeds to operative
production
management
• Indomethacin, ibuprofen
• Indications - symptomatic PDA fails to close
with pharmacologic interventions or who has
• Analgesics – acetaminophen
contraindications to COX inhibitors
• If heart failure symptoms present
•
Surgical ligation
• Fluid restriction
• Transvenous occlusions with coil device
• Diuretics
* PDA closure is more likely when medication is administered before 14-21 days of age.
General contraindications to both
indomethacin and ibuprofen:
• Thrombocytopenia
• Active hemorrhage
(including severe IVH)
• NEC or isolated
intestinal perforation
• High plasma
creatinine
• Oliguria