Ventricular septal defect (VSD)

Ventricular septal defect (VSD)

Definition:

A ventricular septal defect (VSD), also called a hole in the heart, is a common heart defect that's present at birth (congenital). The defect involves an opening (hole) in the heart forming between the heart's lower chambers, allowing oxygen-rich and oxygen-poor blood to mix.

A baby with a small ventricular septal defect may have no problems. A baby with a larger ventricular septal defect or associated heart defects may have a telltale bluish tint to the skin (cyanosis) — due to oxygen-poor blood — often most visible in the lips and fingernails. Ventricular septal defects are sometimes not diagnosed until adulthood.

Fortunately, ventricular septal defect is treatable. Many small ventricular septal defects often close on their own or don't cause problems. Larger ventricular septal defects need surgical repair early in life to prevent complications. Some smaller ventricular septal defects are closed to prevent complications related to their location, such as damage to heart valves. Many people with small ventricular septal defects have normal, productive lives with few related problems.

Symptoms:

Signs and symptoms of serious heart defects often appear during the first few days, weeks or months of a child's life.
Ventricular septal defect symptoms in a baby may include:

• A bluish tint to the skin, lips and fingernails (cyanosis)
• Poor eating, failure to thrive
• Fast breathing or breathlessness
• Easy tiring
• Swelling of legs, feet or abdomen
• Rapid heart rate

Although these signs can be caused by other conditions, they may be due to a congenital heart defect.
You and your doctor may not notice signs of a ventricular septal defect at birth. If the defect is small, symptoms may not appear until later in childhood — if ever. Signs and symptoms vary depending on the size of the hole. Your doctor may first suspect a heart defect during a regular checkup while listening to your baby's heart with a stethoscope.

Sometimes a ventricular septal defect isn't detected until a person reaches adulthood. Signs or symptoms can include shortness of breath and a loud heart murmur your doctor can hear when listening to your heart with a stethoscope.

When to see a doctor
Call your doctor if your baby or child:

• Tires easily when eating or playing
• Is not gaining weight
• Becomes breathless when eating or crying
• Has a bluish tint to his or her skin, especially around the fingernails and lips
• Breathes rapidly or is short of breath

Call your doctor if you develop:

• Shortness of breath when you exert yourself or when you lie down
• Rapid or irregular heartbeat
• Fatigue and weakness
• Swelling (edema) in your legs, ankles and feet

Causes:

Heart defects that are present at birth (congenital) arise from problems early in the heart's development, but there's often no clear cause. Genetics and environmental factors probably play a role.
A ventricular septal defect occurs when the septum, the muscular wall separating the heart into left and right sides, fails to form fully between the lower chambers of the heart (ventricles) during fetal development. This leaves an opening that allows mixing of oxygenated blood and deoxygenated blood, meaning the heart has to work harder to provide enough oxygen to your body's tissues.

If a ventricular septal defect is large, blood overfills the lungs and overworks the heart. If left untreated, the blood pressure in the lungs goes up (pulmonary hypertension) and the ventricles enlarge and no longer work efficiently. Ultimately, this can lead to irreversible damage to the lung arteries and to heart failure. In contrast, small ventricular septal defects don't usually cause any problems, except for a loud heart murmur that doctors may note during physical exams.

Complications:

A small ventricular septal defect may never cause any problems. Larger defects can cause a range of disabilities — from mild to life-threatening. Treatment can prevent many complications.

Eisenmenger's syndrome
If a large ventricular septal defect goes untreated, increased blood flow to the lungs causes high blood pressure in the lung arteries (pulmonary hypertension). Over time, permanent damage to the lung arteries develops and the pulmonary hypertension can become irreversible.

This complication, called Eisenmenger's syndrome, usually develops in early childhood. In people with Eisenmenger's syndrome, a significant portion of blood flows through the ventricular septal defect from the right ventricle to the left and bypasses the lungs.

This means deoxygenated blood is pumped to the body and leads to a bluish discoloration of the lips, fingers and toes (cyanosis) and other complications. Once a person has Eisenmenger's syndrome, it's too late to surgically repair the hole because irreversible damage to the lung arteries has already occurred.

Other complications
Other complications may include:

• Heart failure. The increased blood flow through the heart due to a ventricular septal defect can also lead to heart failure, a chronic condition in which the heart can't pump effectively.
• Endocarditis. People with a ventricular septal defect are at increased risk of an infection of the heart (endocarditis).
• Stroke. People with large defects, especially occurring with Eisenmenger's syndrome, are at risk of a stroke due to a blood clot passing through the hole in the heart and going to the brain.
• Other heart problems. Ventricular septal defects can also lead to abnormal heart rhythms and valve problems.

Ventricular septal defect and pregnancy
Becoming pregnant is often a concern for women born with a heart defect. Having a repaired ventricular septal defect without any complications or having a very small defect doesn't pose any additional risk in pregnancy. However, having an unrepaired larger defect, heart failure, cyanosis or other heart defects poses a high risk to both mother and fetus. Women with Eisenmenger's syndrome are at the highest risk of complications.

Doctors strongly advise these women not to become pregnant.
Any woman with a congenital heart defect, repaired or not, who is considering pregnancy should talk beforehand with a doctor who specializes in the diagnosis and treatment of heart conditions (cardiologist). This is especially important if you're taking medications. It's also important to see both an obstetrician and a cardiologist during pregnancy.

Treatments and drugs:

Many babies born with a small ventricular septal defect won't ever need to have the defect surgically closed. After birth, your doctor may want to observe your baby and treat any symptoms while waiting to see if the defect will close on its own.

Children and adults who have a ventricular septal defect that is large or is causing significant symptoms usually need surgery to close the defect. If your baby has a ventricular septal defect that needs surgical repair, the procedure will likely be scheduled in your baby's first year of life.
Medications
Medications for ventricular septal defect may include those to:

• Keep the heartbeat regular. Examples include beta blockers (Lopressor, Inderal, others) and digoxin (Lanoxin, Lanoxicaps, Lanoxin Pediatric).
• Increase the strength of the heart's contractions. Examples include digoxin (Lanoxin).
• Decrease the amount of fluid in circulation. Doing so reduces the volume of blood that must be pumped. These medications, called diuretics, include furosemide (Lasix).

Procedures
Surgical treatment for ventricular septal defects involves plugging or patching the abnormal opening between the ventricles. Two approaches are used:

• Surgical repair. This is the procedure of choice in most cases. Surgical repair of a ventricular septal defect usually involves open-heart surgery, which is done under general anesthesia. The surgery requires a heart-lung machine and an incision in the chest. The doctor uses patches or stitches to close the hole.
  
• Catheter procedure. This method may be used to close some ventricular septal defects. Patching during catheterization doesn't require opening the chest. Rather than opening the chest, the doctor inserts a thin tube (catheter) into a blood vessel in the groin and guides it to the heart. The doctor then uses a small mesh patch or plug to close the hole.
  
• Hybrid procedure. A hybrid procedure uses surgical and catheter-based techniques. Access to the heart is usually through a small incision and the procedure may be performed without stopping the heart and using the heart-lung machine. A plug is delivered to close the VSD via a catheter placed through the small hole that the surgeon created. Recovery from this procedure is quicker than with standard surgery.

After repair, your doctor will schedule regular medical follow-up to ensure that the ventricular septal defect remains closed. Depending on the size of the ventricular septal defect and the presence or absence of any other problems, your doctor will tell you how frequently you or your child will need to be seen.
Surgery to close a ventricular septal defect generally has excellent long-term results.

Preventive antibiotics
If you've been told in the past that you or your child needs to take antibiotics before dental or medical procedures to reduce the risk of infective endocarditis, talk with your doctor. Endocarditis is much more likely to occur from exposure to random germs than from a typical dental exam or surgery. Current guidelines recommend preventive antibiotic treatment only for those people at highest risk of serious complications from infective endocarditis.
Your doctor may still recommend preventive antibiotics if you:

• Have other heart conditions or artificial valves
• Have a large ventricular septal defect that's causing a low blood oxygen level
• Have had a repair with artificial (prosthetic) material

For most people with a ventricular septal defect, practicing good oral hygiene and getting regular dental checkups is the most effective strategy for preventing endocarditis.