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Ventricular Septal Defect (VSD)

 

INTRODUCTION

Ventricular septal defect (VSD) is one of the most common congenital heart defects, with one out of every 200 babies affected. VSD refers to a “hole” in the wall that separates the two lower chambers of the heart.

 

Many people who are afflicted with this birth defect may not notice symptoms until well after birth.

 

If the VSD is relatively large, it may cause shortness of breath and other problems caused by excessive pulmonary blood flow. Over time, this may lead to pulmonary vascular disease, arrhythmias (irregularities of the heart's rhythm), or congestive heart failure. As such, surgery or a non-surgical procedure may have been done to close the patient's VSD when they were a child. Nevertheless, even if the VSD has been closed, new problems might develop as they get older. The patient should regularly visit a cardiologist.

 

VSD’s can be detected with an echocardiogram where the size of the defect can be measured, along with the blood flow and structure of the heart.

What does this mean for me?

Maybe you first heard about it when you first asked about the scar on your chest as a kid, or you found out when your parents were talking at a doctor’s office. VSDs are a lot more common than people think, with 1 in 5 patients being treated at Peter Munk Cardiac Centre for heart birth defects having VSD. Despite being a common type of heart defect, the exact cause is not known in most patients.

 

In a healthy heart, the right side of the heart pumps blood to the lungs and the left side pumps blood to the rest of the body. In a heart with VSD however, blood is able to travel between the left and right bottom chambers (ventricles) of the heart. This unwanted movement of blood may not cause any symptoms if the size of the defect is small, but a moderate to large sized defect may cause tiredness, shortness of breath, and/or place unwanted stress on the heart and lungs over time. A VSD may be detectable prior to or soon after birth. Long-standing untreated defects may cause high blood pressure in the lungs (pulmonary hypertension) leading to permanent blood vessel damage, or a condition called Eisenmenger Syndrome where the individual also has low oxygen levels (cyanosis) along with pulmonary hypertension.

 

Many small defects close on their own without surgery as children.

 

Pregnant patients

 

In general, most women with an VSD can tolerate pregnancy without any significant problems. This should be considered on a case by case basis by involving a cardiologist who specializes in heart disorders of pregnancy.

 

However, patients with larger defects, who are symptomatic and have VSD-related complications such as arrhythmias or pulmonary hypertension may be at greater risk of developing complications during pregnancy.

 

It is very important to speak to your doctor about becoming pregnant if you have had or have an VSD. The information presented here is of a general nature only and should not be considered medical advice.

 
 

Symptoms: How would I know if I have VSD?

It is often difficult to diagnose a VSD immediately after birth. However if the size of the defect is considered moderate to large, some common signs and symptoms include:

  • Unusual heart rhythms (arrhythmias or atrial fibrillation) may develop, often because of enlargement of the left atrium

  • Weak heart muscle

  • High pressure in the lungs

  • Aortic valve may be damaged if the VSD is adjacent to it, resulting in regurgitation and the potential need for valve repair or replacement

  • Rapid breathing

It is important to note that if the defect is small, these symptoms may not appear until later in life or adulthood, or may never occur, with the VSD only being manifested as a murmur. While these small VSDs will not cause heart failure, shortness of breath, or Eisenmeger's syndrome, the abnormal blood flow through them may predispose them to infection or endocarditis. VSDs in adulthood may be detected during a checkup and your doctor hears a murmur in the heart. Further tests such as an ECG, echocardiogram, and/or MRI may be requested to confirm the existence of the defect. 

Next Steps: Investigation Plan

If the VSD was not diagnosed at birth by a doctor, it may be found during a regular checkup later on. The doctor will perform a physical exam where a heart murmur can be detected.

There are many things that you can help prepare prior to a doctor’s appointment to facilitate the process. Here are some things that you can do:

 

  • Write down key medical information

  • Write down signs and symptoms and the duration

  • Write down questions to ask your doctor

  • Go through the UHN Cardiac clinic website for background information

In addition to a physical exam, the doctor will ask about family health and history, past health, current medications, allergies and any concerns the patient may have. In case a VSD is suspected in a patient, the doctor may order one of the following tests to confirm the VSD:

Treatment Options for VSD

If a patient is diagnosed with VSD, the type of treatment best suited to them will depend on the size and location of the defect and their age. Usually adults rarely require any VSD repair.

 

Treatment options include:

  • Surgery to repair the VSD and any other coexisting valve problems.

  • Having a nonsurgical, percutaneous (through the skin) procedure to repair your VSD

  • Continuing to monitor your VSD

 

The intracardiac repair involves an open heart surgery where the surgeon makes a cut through the chest and the patient is under general anesthesia. A patch of manmade surgical material is stitched over the defect where the heart eventually heals over the patch with your own tissue.

 

The transcatheter technique is a non-surgical technique does not require cutting through the chest. Usually, the VSD is crossed from the arterial side with a wire. This is snared from the right side of the heart and brought out through the skin over the leg vein. The device is placed at the end of a catheter (a long thin tube). It is inserted into a vein in the groin and pushed over the wire and through the VSD hole. Your doctor guides the catheter and the device by using x-ray and ultrasound (intra-cardiac echocardiogram). Once the device is in position, it is pushed out of the catheter so it could open up and ‘plug’ the VSD hole.

 

Over time, your tissue grows over the implant and it becomes part of the heart.

 

After your VSD procedure, you will be prescribed an anticoagulant, for example, aspirin, clopidogrel or warfarin (Coumadin), usually for 6 months to prevent blood clots from forming on the device.


 

Post procedure, the doctor will set up regular follow-up visits to ensure that the VSD procedure has gone smoothly and the VSD remains closed.

Causes: Why do I have VSD?

VSDs are present at birth and occur during the fetal heart development stage. The heart initially starts out from a large tube, which further divides into sections that become the heart walls and chambers. If there is a problem that occurs in this process, it may result in a hole between the lower heart chambers.

 

A family history of VSD or other heart birth defects may increase the chance of passing it on to further generations, also affected by environmental factors such as drugs and/or illnesses.

 
 

Transesophageal Echocardiogram (TTE)

 

VSDs are usually initially assessed with transthoracic echocardiograms (TTE). TTE allows us to get an estimate of the VSD size, and function of the aortic valve. We will also assess the size of the left ventricle. Enlargement of the left ventricle suggests that the VSD is having an impact on heart function. Lastly, we will try to estimate the pulmonary artery pressure, this is usually difficult if the pulmonary artery pressure is elevated. Your doctor may want to measure this with a cardiac catheterization

 

 

Transesophageal Echocardiogram (TEE)

By swallowing the TEE probe (similar to the camera used to look at the stomach), your doctor will be able to see the ventricular septum from the inside.

Long Term Health Implications

Small defects in the lower heart chambers usually close on their own in childhood. However if moderate to large VSDs are left untreated, it will make the heart and lungs work harder than they are meant to work, and complications may arise.

 

Because the pressure in the bottom left chamber is greater than the bottom right, the blood will move (shunt) from the left chamber to the right chamber. This causes problems because the blood in the bottom left chamber is filled with oxygen from the lungs, so excess oxygenated blood is flowing back to the lungs. (Diagram)

 

As a result, high blood pressure (pulmonary hypertension) may occur in the lung blood vessels since there is more blood being pumped than normal. If people with pulmonary hypertension have low oxygen levels or cyanosis, this is a more serious condition, called Eisenmenger Syndrome. Pulmonary hypertension may cause heart, lung, and blood problems. If permanent lung and heart damage occurs, VSD closure may no longer be an option. If you have pulmonary hypertension, you need to be seen regularly in an Adult Congenital Heart Disease Clinic.

 

People with VSDs are also more at risk for having an infection of the heart lining caused by bacteria (endocarditis). Long-term untreated endocarditis can also cause permanent and severe damage to the heart valves.

Electrocardiogram (ECG)

The ECG  is  the best  way to identify your heart rhythm and to determine whether any of the heart chambers are enlarged. It may also suggest other issues of importance we may need to deal with at the time of your procedure.

Magnetic Resonance Imaging (MRI)

 

An MRI of the heart may play an important role in some patients suspected of having a VSD. MRI is the gold standard for measuring the left ventricle. MRI images can be used to calculate a very accurate volume of the left ventricle. In patients with small VSDs, this will help us to decide if the VSD needs to be closed. In some patients we cannot find all of the pulmonary veins on TEE. MRI is the best at finding these “missing veins”.

 

Holter Monitor

A Holter monitor is a small recording device which attaches to leads on the chest. It monitors the heart rhythm continuously for up to 2 weeks. If you complain of palpitations (i.e. extra beats or fast heart beats), your doctor may ask for a Holter prior to the VSD closure procedure.

Frequently Asked Questions

 

Are there any lifestyle restrictions following VSD closure?

 

In general, there are minimal lifestyle restrictions following VSD closure.  VSD closure is performed to return people to normal functioning and health. Given the procedure is performed through punctures in the blood vessels in the leg, we caution against vigorous exercise in the 2 weeks following the procedure. We would like those punctures to completely heal before any form of aggressive exercise is performed.

 

 

Will I need any further treatments following treatment?

 

 

In the short term following your procedure, you will be given a follow-up appointment to monitor your progress. You will see the doctor and an echocardiogram will be performed. If all is well, your doctor will send you back to your local physician. If there are any unresolved issues or questions your doctor may elect to have you follow up again to make sure all is well.  A complication of trans-catheter VSD closure may include hemolysis or breakdown of red blood cells. Ask your doctor about this.

 

 

Can I play sports?

 

 

You may return back to your normal physical activities after 14 days or so. You should start off by walking at a normal pace and gradually begin increasing aerobic exercise intensity after the second week. Contact sports should be avoided for at least a month after surgery.

 

 

Will OHIP (public insurance) cover my VSD closure?

 

Yes. 

 

 

How urgent is the treatment?

The urgency of treatment is highly dependent on your situation. It is rare for a VSD closure to be truly urgent. In most cases, there is no urgent need to repair the hole. If treatment is required, the urgency depends on the type, location, and size of the hole, in addition to signs of atrial enlargement. Usually, a delay of several months is not significant. It is more important to thoroughly assess the problem than to jump in and perform a procedure urgently.

 

 

Questions?

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Toronto General Hospital 

 200 Elizabeth Street | 6E - 249

Toronto, Ontario M5G 2C4

Tel: 416-340-3835

Fax: 416-340-3000

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