Ventricular Septal Defect
A ventricular septal defect (VSD) is a hole in the part of the septum that separates the ventricles. (The ventricles are the lower chambers of the heart.)
A VSD allows oxygen-rich blood to flow from the left ventricle into the right ventricle, instead of flowing into the aorta as it should. So, instead of going to the body, the oxygen-rich blood is pumped back to the lungs, where it has just been.
Cross-Section of a Normal Heart and a Heart With a Ventricular Septal Defect
Figure A shows the structure and blood flow inside a normal heart. Figure B shows two common locations for a ventricular septal defect. The defect allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood in the right ventricle.
An infant who is born with a VSD may have one or more holes in the wall that separates the two ventricles. The defect also may occur alone or with other congenital heart defects.
Doctors will classify a VSD based on the:
- Size of the defect.
- Location of the defect.
- Number of defects.
- Presence or absence of a ventricular septal aneurysm—a thin flap of tissue on the septum. This tissue is harmless and can help a VSD close on its own.
VSDs can be small, medium, or large. Small VSDs don't cause problems and may close on their own. Small VSDs sometimes are called restrictive VSDs because they allow only a small amount of blood to flow between the ventricles. Small VSDs don't cause any symptoms.
Medium VSDs are less likely to close on their own. They may cause symptoms in infants and children. Surgery may be needed to close medium VSDs.
Large VSDs allow a lot of blood to flow from the left ventricle to the right ventricle. They're sometimes called nonrestrictive VSDs. Large VSDs likely won't close completely on their own, but they may get smaller over time.
Large VSDs often cause symptoms in infants and children. Surgery usually is needed to close large VSDs.
VSDs are found in different parts of the septum.
- Membranous VSDs are located near the heart valves. These VSDs can close at any time.
- Muscular VSDs are found in the lower part of the septum. They're surrounded by muscle, and most close on their own during early childhood.
- Inlet VSDs are located close to where blood enters the ventricles. They're less common than membranous and muscular VSDs.
- Outlet VSDs are found in the part of the ventricle where blood leaves the heart. These are the rarest type of VSD.
Ventricular Septal Defect Complications
Over time, if a VSD isn't repaired, it may cause heart problems. A medium or large VSD can cause:
- Heart failure. Infants who have large VSDs may develop heart failure. This is because the left side of the heart pumps blood into the right ventricle in addition to its normal work of pumping blood to the body. The increased workload on the heart also increases the heart rate and the body's demand for energy.
- Growth failure, especially in infants. A baby may not be able to eat enough to keep up with his or her body's increased energy demands. As a result, the baby may lose weight or not grow and develop normally.
- Arrhythmias. The extra blood flowing through the heart can cause areas of the heart to stretch and enlarge. This can disturb the heart's normal electrical activity, leading to irregular heartbeats.
The high pressure and high volume of extra blood pumped through a large VSD into the right ventricle and lungs can scar the lung's arteries. This proble
What Are the Signs and Symptoms of Holes in the Heart?
Atrial Septal Defect
Many babies who are born with atrial septal defects (ASDs) have no signs or symptoms. However, as they grow, these children may be small for their age.
When signs and symptoms do occur, a heart murmur is the most common. A heart murmur is an extra or unusual sound heard during a heartbeat.
Often, a heart murmur is the only sign of an ASD. However, not all murmurs are signs of congenital heart defects. Many healthy children have heart murmurs. Doctors can listen to heart murmurs and tell whether they're harmless or signs of heart problems.
If a large ASD isn't repaired, the extra blood flow to the right side of the heart can damage the heart and lungs and cause heart failure. This generally doesn't occur until adulthood. Signs and symptoms of heart failure include:
- Fatigue (tiredness)
- Tiring easily during physical activity
- Shortness of breath
- A buildup of blood and fluid in the lungs
- Swelling in the ankles, feet, legs, abdomen, and veins in the neck
Ventricular Septal Defect
Babies born with ventricular septal defects (VSDs) usually have heart murmurs. Murmurs may be the first and only sign of a VSD. Heart murmurs often are present right after birth in many infants. However, the murmurs may not be heard until the babies are 6 to 8 weeks old.
Most newborns who have VSDs don't have heart-related symptoms. However, babies who have medium or large VSDs can develop heart failure. Signs and symptoms of heart failure usually occur during the baby's first 2 months of life.
The signs and symptoms of heart failure due to VSD are similar to those listed above for ASD, but they occur in infancy.
A major sign of heart failure in infancy is poor feeding and growth. VSD signs and symptoms are rare after infancy. This is because the defects either decrease in size on their own or they're repaired.
How Are Holes in the Heart Diagnosed?
Doctors usually diagnose holes in the heart based on a physical exam and the results from tests and procedures. The exam findings for an atrial septal defect (ASD) often aren't obvious. Thus, the diagnosis sometimes isn't made until later in childhood or even in adulthood.
Ventricular septal defects (VSDs) cause a very distinct heart murmur. Because of this, a diagnosis usually is made in infancy.
Doctors who specialize in diagnosing and treating heart problems are called cardiologists. Pediatric cardiologists take care of babies and children who have heart problems. Cardiac surgeons repair heart defects using surgery.
During a physical exam, your child's doctor will listen to your child's heart and lungs with a stethoscope. The doctor also will look for signs of a heart defect, such as a heart murmur or signs of heart failure.
Diagnostic Tests and Procedures
Your child's doctor may recommend several tests to diagnose an ASD or VSD. These tests also will help the doctor figure out the location and size of the defect.
Echocardiography (echo) is a painless test that uses sound waves to create a moving picture of the heart. The sound waves (called ultrasound) bounce off the structures of the heart. A computer converts the sound waves into pictures on a screen.
Echo allows the doctor to clearly see any problem with the way the heart is formed or the way it's working.
Echo is an important test for both diagnosing a hole in the heart and following the problem over time. Echo can show problems with the heart's structure and how the heart is reacting to the problems. This test will help your child's cardiologist decide whether and when treatment is needed.
An EKG is a simple, painless test that records the heart's electrical activity. The test shows how fast the heart is beating and its rhythm (steady or irregular). It also records the strength and timing of electrical signals as they pass through the heart.
An EKG can detect whether one of the heart's chambers is enlarged, which can help diagnose a heart problem.
Chest X Ray
A chest x ray is a painless test that creates pictures of the structures in the chest, such as the heart, lungs, and blood vessels.
This test can show whether the heart is enlarged. A chest x ray also can show whether the lungs have extra blood flow or extra fluid, a sign of heart failure.
Pulse oximetry shows the level of oxygen in the blood. A small sensor is attached to a finger or ear. The sensor uses light to estimate how much oxygen is in the blood.
During cardiac catheterization, a thin, flexible tube called a catheter is put into a vein in the arm, groin (upper thigh), or neck. The tube is threaded to the heart.
Special dye is injected through the catheter into a blood vessel or one of the heart's chambers. The dye allows the doctor to see the flow of blood through the heart and blood vessels on an x-ray image.
The doctor also can use cardiac catheterization to measure the pressure inside the heart chambers and blood vessels. This can help the doctor figure out whether blood is mixing between the two sides
How Are Holes in the Heart Treated?
Many holes in the heart don't need treatment, but some do. Those that do often are repaired during infancy or early childhood. Sometimes adults are treated for holes in the heart if problems develop.
The treatment your child receives depends on the type, location, and size of the hole. Other factors include your child's age, size, and general health.
Treating an Atrial Septal Defect
If a child has an atrial septal defect (ASD), routine checkups are done to see whether it closes on its own. About half of all ASDs close on their own over time, and about 20 percent close within the first year of life.
Your child's doctor will let you know how often your child should have checkups. For an ASD, frequent checkups aren't needed.
If an ASD requires treatment, catheter or surgical procedures are used to close the hole. Doctors often decide to close ASDs in children who still have medium- or large-sized holes by the time they're 2 to 5 years old.
Until the early 1990s, surgery was the usual method for closing all ASDs. Now, thanks to medical advances, doctors can use catheter procedures to close secundum ASDs. These are the most common type of ASD.
Before a catheter procedure, your child is given medicine so he or she will sleep and not feel any pain. Then, the doctor inserts a catheter (a thin, flexible tube) into a vein in the groin (upper thigh). He or she threads the tube to the heart's septum. A device made up of two small disks or an umbrella-like device is attached to the catheter.
When the catheter reaches the septum, the device is pushed out of the catheter. The device is placed so that it plugs the hole between the atria. It's secured in place and the catheter is withdrawn from the body.
Within 6 months, normal tissue grows in and over the device. The closure device does not need to be replaced as the child grows.
Doctors often use echocardiography (echo), transesophageal echo (TEE), and coronary angiography to guide them in threading the catheter to the heart and closing the defect. TEE is a special type of echo that takes pictures of the heart through the esophagus. The esophagus is the passage leading from the mouth to the stomach.
Catheter procedures are much easier on patients than surgery. They involve only a needle puncture in the skin where the catheter is inserted. This means that recovery is faster and easier.
The outlook for children having this procedure is excellent. Closures are successful in more than 9 out of 10 patients, with no major leakage. Rarely, a defect is too large for catheter closure and surgery is needed.
Open-heart surgery generally is done to repair primum or sinus venosus ASDs. Before the surgery, your child is given medicine so he or she will sleep and not feel any pain.
Then, the cardiac surgeon makes an incision (cut) in the chest to reach the ASD. He or she repairs the defect with a special patch that covers the hole. A heart-lung bypass machine is used during the surgery so the surgeon can open the heart. The machine takes over the heart's pumping action and moves blood away from the heart.
The outlook for children who have ASD surgery is excellent. On average, children spend 3 to 4 days in the hospital before going home. Complications, such as bleeding and infection, are very rare.
In some children, the outer lining of the heart may become inflamed. This condition is called pericarditis. The inflammation causes fluid to collect around the heart in the weeks after surgery. Medicine usually can treat this condition.
While in the hospital, your child will be given medicine as needed to reduce pain or anxiety. The doctors and nurses at the hospital will teach you how to care for your child at home.
They will talk about preventing blows to the chest as the incision heals, limiting activity while your child recovers, bathing, scheduling ongoing care, and deciding when your child can go back to his or her regular activities.
Treating a Ventricular Septal Defect
Doctors may choose to monitor children who have ventricular septal defects (VSDs) but no symptoms of heart failure. This means regular checkups and tests to see whether the defect closes on its own or gets smaller.
More than half of VSDs eventually close, usually by the time children are in preschool. Your child's doctor will let you know how often your child needs checkups. Checkups may range from once a month to once every 1 or 2 years.
If treatment for a VSD is required, options include extra nutrition and surgery to close the VSD. Doctors also can use catheter procedures to close some VSDs. They may use this approach if surgery isn't possible or doesn't work. More research is needed to find out the risks and benefits of using catheter procedures to treat VSDs.
Some infants who have VSDs don't grow and develop or gain weight as they should. These infants usually:
- Have large VSDs
- Are born too early
- Tire easily during feeding
Doctors usually recommend extra nutrition or special feedings for these infants. These feedings are high-calorie formulas or breast milk supplements that give babies extra nourishment.
Some infants need tube feeding. A small tube is inserted into the mouth and moved down into the stomach. Food is given through the tube.
Tube feeding can add to or take the place of bottle feeding. This treatment often is short-term because a VSD that causes symptoms will likely require surgery.
Most doctors recommend surgery to close large VSDs that are causing symptoms, affecting the aortic valve, or haven't closed by the time children are 1 year old. Surgery may be needed earlier if:
- A child doesn't gain weight
- Medicines are needed to control the symptoms of heart failure
Rarely, medium-sized VSDs that are causing enlarged heart chambers are treated with surgery after infancy. However, most VSDs that require surgery are repaired in the first year of life. Doctors use open-heart surgery and patches to close VSDs.