Ventricular septal defect Moderator – Dr Bhalla Presentor – Dr Priya www.anaesthesia.co.in [email protected]
Dec 18, 2015
Ventricular septal defect
Moderator – Dr BhallaPresentor – Dr Priya
www.anaesthesia.co.in
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