echocardiograohic evalution of VSD

1. Presented by
Dr. Waseem Omar
A. Lecturer of cardiology

2.  The ventricular septal defect is a communication
within the interventricular septum allowing shunting
of blood between the ventricles.
 VSDs are the commonest isolated congenital heart
defect in children represent 20% of congenital heart
disease.
 VSDs are frequently associated with more complex
cardiac malformations.

3. Classification:
 Membranous (Gerbode defect).
 Perimembranous.
 Trabecular (Muscular).
 Outlet: supracristal, infracristal
Also called infundibular or conal.
 Inlet: Also called AV canal (AVC) type defects.

5. Membranous (Gerbode defect).
 The membranous septum is a very small area located
between the anterior and septal leaflets of the TV.
 The defect is above the TV, which overlaps a small
segment of the RA.
 Results in a LV-to-RA shunt.

8. Perimembranous VSDs
 A defect in the IVS adjacent to the
membranous portion of the IVS and septal
leaflet of the TV.
 Most common type of VSD represent 80% of
all VSDs.

9.  Best imaged in:
Parasternal long axis view.
Parasternal short axis view at 10 o’clock.
Apical 5 chambers view.

12. VSDsMuscular
 Second most common type of VSD.
 Can be located anywhere in the muscular septum,
including: Anterior, posterior, mid, and apical.
 Multiple muscular VSDs with a net moderate to
large shunt may be referred to as “Swiss cheese”
defects.

13.  Best imaged in:
Parasternal long axis view.
Subcostal and parasternal short axis view for
anterior to posterior assessment.
Apical views for base-to-apex assessment.

16. Inlet VSDs
 Located posterior and superior in the inlet
septum beneath the septal leaflet of the TV.
 Associated with endocardial cushion defects
(also called AVC defects) including AVV
defects and primum ASDs.

17. Best imaged in:
Apical 4 chambers view.
PSAX (mitral valve/basal septal level)

20. Outlet VSDs
 Located inferior and anterior to the
pulmonary valve.
 Defects do not close spontaneously.
 Least common defect, representing 6% of
VSDs.

21.  Best imaged in: PSAX
Supracristal PSAX—aortic valve (2 o’clock)
Infracristal PSAX—aortic valve level (~12
o’clock)

25. 1: Evaluate the Ventricular Septal Defect
Location and Type:
 The IVS is a three-dimensional (3D) structure
requires multiple imaging planes for evalution.
 Use both two-dimensional (2D) and color Doppler
mapping to identify ventricular shunting lesions.
 Scan the entire septum from the base to the apex
of the heart.

26. 2: Evaluate Ventricular Septal Defect
Size:
 VSDs are classified as:
Small: less than one third LVOT diameter.
Moderate: one third to two thirds LVOT
diameter.
Large: greater than two thirds LVOT diameter.

27.  Measurements should be obtained on 2D
images as measurements obtained on
images with color Doppler overestimate
size.

28. 3: Evaluate the Direction of the Shunt:
 Shunting primarily occurs in systole.
 The shunt is left to right in smaller lesions with
normal pulmonary resistance.
 Both color Doppler and spectral Doppler
evaluation are useful when evaluating shunt
direction.

29. 4: Evaluate the Effects of Shunting:
 Volume overload is reflected by:
Left atrial dilation.
Left ventricular enlargement and
hypertrophy.

30.  Pulmonary hypertension may be present reflecting
changes from chronic volume overload.
 Estimate PA pressure (in the absence of pulmV
disease) using a tricuspid regurgitation (TR) jet.
 Take care to avoid contamination of the TR jet
from the VSD jet.

35. Transcatheter closure can be considered in
patients with:
Increased risk factors for surgery.
Multiple previous cardiac surgical interventions.
VSDs that are poorly accessible for surgical closure.
 In muscular VSDs that are located centrally in the
interventricular septum.

36. Transcatheter closure is not suitable in:
Supracrystal VSD.
Malalignement VSD.
Associated significant aortic regurgitation.
Prolapse of aortic cusp.
Sub-aortic stenosis.
Sub-pulmonary stenosis.

38.  3D echocardiography permits projection of
an en face view of the VSD from which
accurate sizing can be performed
irrespective of the shape or location of the
defect.

39.  VSDs may often have unusual or irregular
shapes and the 3D technique has the ability
to display such morphology and assist in the
selection of the appropriate occlusion device

40.  Assessment of adjacent structures and “rims”
of the VSD is a major strength of 3D
echocardiography compared to 2D
echocardiography, because all rims around
the defect can be visualized in a single
sonographic projection and viewed from
either the left or right ventricle.

41.  With the use of live 3D echocardiography,
the precise orientation of the occlusion
device and guidance of catheters can be
accurately monitored.