Ventricular Septal Defect (VSD)
What is a Ventricular Septal Defect?
A VSD, or Ventricular Septal Defect, is a ‘’hole" or "holes" between the bottom two chambers of the heart. The "hole" or "holes" may be single or multiple. It can be located anywhere along the ventricular septum, the wall dividing the ventricles of the heart, appearing high, in the middle, or low on the septal wall. The defect may be small, medium-sized, or large and may sometimes be associated with other defects of the heart.
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What do Ventricular Septal Defects do?
In the normal heart, the wall (septum) between the ventricles is meant to separate the "blue" or deoxygenated blood from the "red" or oxygenated blood. When a hole exists in this wall, mixing of the "blue" and "red" blood occurs. The "red" blood from the high-pressured left side of the heart flows across the hole in the septum to the low-pressured right side of the heart, and mixes with the "blue" blood. Blood will normally only flow from places of high pressure to places of low pressure.
What happens if Ventricular Septal Defects are left untreated?
Because of the "Left to Right" shunt of blood across the Ventricular Septal Defect, the right side of the heart now receives blood from two places and has to pump more blood than normal to the lungs. The right heart is overworked with the extra load, and the lungs can become damaged from the extra blood flow. When excessive pulmonary blood flow occurs over an extended period of time, the lung blood vessels become very thick and hard. This condition is called Pulmonary Hypertension. In this situation, lung damage is usually irreversible and even repairing the septal defect may not cure the disease.
When the Ventricular Septal Defect is located very high on the septum, close to the Aortic Valve, the flow across the VSD can injure the leaflets of the valve causing it to leak. This condition, known as Aortic Regurgitation, usually takes many years to occur.
Small infants expend large amounts of energy for growth and weight gain in the first few months of life. When an infant is born with a Ventricular Septal Defect a huge amount of energy is expended by the infant to allow the heart to work efficiently. Energy that may have been utilized to help the infant grow and gain weight is now being expended just to keep the heart working. The child therefore has poor weight gain and very slow growth. When there are multiple Ventricular Septal Defects, or one very large VSD in a small infant or child, lung blood flow may be so excessive that the tiny heart cannot pump efficiently and may begin to wear out. When the heart does not pump well, Congestive Heart Failure may occur. Some signs and symptoms of heart failure include sweating, rapid breathing, poor weight gain, irritability, and general failure to grow well.
In small Ventricular Septal Defects, none of these conditions occurs very often. Some VSD’s close without any treatment at all, although there is no definite way to predict which ones will close spontaneously and which ones will go on to require a surgical intervention for closure. It seems that the best chance for closure is in the first 6 months to 1 year of life. After this spontaneous closure becomes more rare.
Should a Ventricular Septal Defect be repaired?
Decision-making in this area is very complex. The cardiologists and the cardio-thoracic surgeon take many factors into consideration. These factors include the age of the child, the location and size of the VSD, the level of lung involvement, and the severity of the Congestive Heart Failure.
In small babies with moderate to severe heart failure, usually with a large Ventricular Septal Defect or multiple VSD’s, surgical repair may be indicated immediately. Small to moderate sized Ventricular Septal Defects may be managed medically, on medications such as Digoxin and Lasix, to help the function of the heart and to decrease the amount of fluid that can build up in the child’s lungs from the increased blood flow. This of course would depend on the amount of Congestive Heart Failure that the patient was in, as well as the growth of the patient. Medical management of the patient would allow for the hole to close spontaneously, or for the patient to grow, and to gain weight and strength in preparation for the surgical closure of the defect should it be needed.
Small VSD’s with a small amount to no related heart failure lend themselves to much controversy on the idea of closure. The decision to repair these small defects would depend largely on the philosophy of the cardiologists and the surgeon.
When should a Ventricular Septal Defect be repaired?
Again this decision is a very complex one. Factors such as the age of a patient, the size and the location of the VSD, the severity of the lung damage and the severity of the Congestive Heart Failure all must be considered.
In small babies with severe heart failure, repair will be recommended immediately. If there is no heart failure, repair may be post-poned until the patient starts showing signs of heart failure.
Moderate sized VSD’s may be followed and managed medically for a longer period of time. Ventricular Septal Defects that involve the Aortic Valve Leaflets need to be followed closely for signs of valve leakage. If signs of leakage are apparent, the recommendation would be to close the VSD as soon as possible.
There comes a point when the degree of Pulmonary Hypertension becomes the deciding factor in the question of whether or not a VSD should be closed. With low to moderately high pulmonary pressures closure would be strongly recommended. If the patient has high pulmonary pressures, closing the VSD may actually be worse for the patient than leaving it open.
How are Ventricular Septal Defects Closed?
In order to close a Ventricular Septal Defect the child must under go an "open heart operation". The defect may be closed through the right atrium, the right ventricle, the aorta, or the pulmonary artery, depending on the location of the hole in the septum.
When the VSD is small, the hole may be closed "primarily", or by stitching the sides of the hole together without the use of a synthetic patch. When the defect is of moderate to large size, and/or has multiple holes, a synthetic patch made of Dacron or Gortex is stitched into the septum covering the hole or holes of the defect.
Is Ventricular Septal Defect closure a safe procedure?
No surgery is ever 100 % safe, but the closure of a VSD is a reasonably safe procedure. The patient has to go through an "open heart operation" and the risks are directly related to this procedure. Some of these risks include bleeding requiring a blood transfusion, infection, and of course the risk of death (although it is very low, at 1-3% for VSD closures).
One of the risks that may occur more in Ventricular Septal Defect repairs is the risk of an Arrythmia called Complete Heart Block. This may occur more frequently in VSD closures due to the area of the heart where the repair takes place. The conduction system of the heart passes very close to the margins of some of the Ventricular Septal Defects. When the VSD is stitched closed, sometimes a stitch may pass too close to the conduction tissue, causing a break in the impulse when it is passed from the AV Node down the ventricular muscles of the heart. As a result the impulse is not carried normally and the conduction system of the heart may be compromised. In most VSD closures the surgeon will attach temporary pacing wire to the outside of the heart prior to closing the chest. If a patient should develop any arrythmias during the post-op period these wires can be attached to a temporary External Pacemaker. In most cases Heart Block is temporary and usually resolves within a few days of the surgery. The patient will remain hooked to the External Pacemaker until normal heart rhythm returns. If a spontaneous normal rhythm does not occur, the surgeon will recommend the placement of a Permanent Pacemaker at around 5-7 days after surgery.
Will my child be "normal after the closure of a Ventricular Septal Defect?
Fortunately, most children do very well, and most are leading normal lifestyles with mild to no restrictions. For 5-6 weeks post-op, there will be some limitations on the physical activities of the child. Most will not be cleared to return to school for at least two weeks after the operation. The surgeon and the cardiologists will closely monitor the child for a few months after the surgery. Some children may have to be on antibiotics to decrease the risk of infections that may spread to the heart before some minor operations, and/or having their teeth worked on. Other than these children who have their VSD’s repaired and who have no other illnesses live normal, healthy lives.
Contact Information:
John Mark Morales MD, FACS, FAAP
Chief of Cardiothoracic, Director of Perfusion Services
Certified by the American Board of Surgery, American Board of Thoracic SurgeryMark Bielefeld, MD
Driscoll Children's Hospital Chief of Staff
Certified by the American Board of Surgery, American Board of Thoracic SurgeryThoracic surgeons are available for questions and consultations: (361) 854-0201. For appointments, assistance, and physician references in Corpus Christi call:
(361) 854-0201 or (800) DCH-LOVE
Fax : 361-855-7572
E-MAILS : Mark Morales, MD
Mark Bielefeld, MD
For further information on any surgical procedures you can contact Carol Kaplan, RN, Surgical Nurse Liaison at (361) 694-5150. Consultation and surgery for inpatients is provided in concert with neonatology and pediatric cardiology departments. Complete evaluation and management for infants, children, adolescents and adults with congenital or acquired cardiac, vascular or thoracic anomalies.
Cardiothoracic Associates
3533 S. Alameda, Suite 202
Corpus Christi, Texas 78411
Office: (361) 854-0201 or (361) 694-5150
Fax: (361) 855-7572
Hours: 9am to 6pm
Fri 9am to 5pm
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Copyright © Driscoll Children's Hospital 2008
Corpus Christi, Texas
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