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Nguyen Lan HieuManagement of VSD tài liệu, giáo án, bài giảng , luận văn, luận án, đồ án, bài tập lớn về tất cả các lĩnh...
Management of VSD (Ventricular septal defect) Overview The most common lesion seen in congenital heart disease (about 2.5 per 1000 live births) Ventricular defects may be located anywhere in the ventricular septum, single or multiple, of variable size and shape, with associated defects Ventricular defects are classified by their location in the septum -> types Anatomy Anatomy Membranous defects: Originally considered the most common type, are now just more common in complicated lesions than muscular defects A small translucent structure located immediately superior to the division of the septal band and adjacent to the commissure between the anterior and septal leaflets of the tricuspid valve It lies directly under the aortic valve on the left side and overlaps a small segment of the right atrium Associated aortic valvar abnormalities, ventricular Aortic rim VSD & PDA Restrictive VSD: PDA closure alone may be benificial Significant lesions in very young patients: surgical closure of both defects Normally growing infant with clearly restrictive defects may be followed medically; if PDA persists, it may be closed by coiloccluded catheterization VSD & PDA Older patient with significant lesions and low pulmonary resistance: close defects surgically or by devices Elevated pulmonary resistance suspected: catheterization to evaluate response to oxygen & nitric oxide and temporary occlusion and device closure of the ductus if indicated COURSE VSDs with Pulmonary stenosis: a) Acyanotic Tetralogy of Fallot: differential diagnosis by large VSD, infundibular pulmonary stenosis, overriding aorta, the systemic level right ventricular pressure b) Ventricular defect and valvar pulmonary stenosis: Treatment is indicated or not depends on the severity of the defects c) VSD with double-chambered right ventricle: Muscle bundles traverse and obstruct the right ventricular outflow tract, lesion is usually COURSE VSD & Mitral valve (MV) disease: a) VSD & Mitral valve stenosis: Minimal MV stenosis, moderate or less pulmonary hypertension: management is the same as that for the usual VSD Moderate MV stenosis, VSD of some size, there will be systemic levels of pressure in the pulmonary artery The amount of left-to-right shunting depends largely on the comparative levels of pulmonary & systemic resistance VSD & Mitral valve stenosis Severe MV stenosis, level of pulmonary resistance may become so high -> ventricular shunting reverses, cyanosis The ultimate success of management depends on the success in treating MV stenosis Infant with severe MV stenosis, large VSD: surgical defect closure + valvuloplasty If VSD is small: ballon dilation may apply to MV stenosis VSD & Mitral valve stenosis Older patient with large VSD, significant MV stenosis: Catheterization for hemodynamic evaluation If there is high pulmonary resistance, ballon dilation may relieve stenosis, decrease resistance & increase left-to-right shunting to close VSD safely COURSE b) VSD & mitral regurgitation: management depends on clinical status, degree of regurgitation, size of VSD Both lesions are mild: medical management indicated Large left-to-right shunt at the ventricular level & not severe regurgitation: VSD closure alone may improve the regurgitation Severe regurgitation: valvuloplasty is usually effective in the short term Catheterization data in a 4-months-old infant with 2:1 left-to-right shunt, membranous VSD (black arrow), and moderate mitral regurgitation through anterior leaflet cleft (open arrow) Four years later, the VSD had spontaneously closed, and at age 10 years, the mitral cleft was successfully closed surgically SUMMARY Type Size AP/PS RP/RS Qp/Qs Ia Resistive