Ventricular septal defect
|Classification according to ICD-10|
|Q21.0||Ventricular septal defect|
|ICD-10 online (WHO version 2019)|
The ventricular septal defect (VSD, not to be confused with the identical abbreviation for an atrial septal defect ) or ventricular septal defect is a hole in the septum and with about 35% of the most common of all congenital heart defects . VSD and its symptoms are also known as Roger's disease . In the embryonic phase of heart development, the upper and lower parts of the septum between the heart chambers (ventricles) grow towards each other ( septum interventriculare ). If this growth is disturbed and not quite complete at birth , there is a more or less large defect in the muscular or membranous part of the ventricular septum ( substance defect of the ventricular septum ). A VSD also occurs in around half of all complex heart malformations, but in these cases it is to be assessed differently from the isolated VSD described here .
The need for treatment ( intervention ) depends on the symptoms , on the location, on the opening area ( defect size , often given as a ratio to the body surface area ), on the shunt minute volume (shunt volume, flow rate, volume flow, volume flow , shunt time volume, volume per unit of time, often given as a percentage of the stroke volume , of the cardiac output and sometimes of the lung output ), of the direction of flow (right-left shunt or left-right shunt) and of the accompanying diseases . The transition between the indication for surgery and the wait- and- see behavior is fluid. The basic formula applies cardiac output plus left-right shunt volume flow equal to lung time volume plus right-left shunt volume flow.
A vertricular septal defect is a hole in the heart septum at the ventricular level . A corresponding hole at the atrial level is called atrial septal defect , atrial septal defect or atrial septal defect with the abbreviation ASD.
In addition to congenital defects, there are also acquired ventricular septal defects, for example after a ventricular rupture .
Classification according to defect location:
- Perimembranous VSD: Opening (s) in the membranous ventricular septum, near the tricuspid valve and / or the aortic valve
- Muscular VSD: single or multiple ( Swiss cheese defect ) occurring defect, purely muscularly limited (central or apical)
- So-called. “Doubly committed VSD”: opening below the aortic and pulmonary valves
- AV channel type ( inlet type ): opening in the area of the inlet septum of the right ventricle
Effects on the cardiovascular system
The pressure in the left ventricle ( body circulation ) is approx. 4 to 5 times higher than the pressure in the right ventricle ( pulmonary circulation ). Therefore, depending on the size of the defect, the VSD pumps more or less arterialized (oxygen-rich) blood through the hole into the right ventricle. This crossover is called a left-right shunt and puts a strain on the pulmonary vasculature. If a large, hemodynamically effective VSD persists over a long period of time, pulmonary hypertension can develop.
Depending on the size of the left-right shunt, a more or less pronounced heart failure (reduced cardiac output with a reduction in cardiac output depending on the shunt volume flow, i.e. the volume flow or the flow rate) can occur. A congestion of the increased blood flow in the lungs leads to increased fluid storage in the tissue - in acute cases to pulmonary edema . The shunt volume can be between 20 and 500% of the cardiac output.
In addition, as with all septal defects , paradoxical (i.e. crossed) embolisms ( ischemic , thromboembolic strokes ) can occur. These emboli are called crossed because they cross the heart septum . They are called paradoxical because they cause a cerebral infarction instead of a pulmonary embolism . This increases the likelihood of all cerebral embolisms ( thromboembolism , air embolism , fat embolism , amniotic fluid embolism , and so on).
The children are often noticed by increased breathing. Drinking is difficult for them due to the increased cardiac output and lung output . Gaining weight can be difficult with normal height gain ( failure to thrive ). This is why VSD children are often very slim.
In the case of very large defects, heart failure can therefore occur very early with such a strong increase in pulmonary vascular resistance that a shunt reversal develops in the sense of an Eisenmenger reaction . In very severe cases, arterial undersaturation with oxygen can lead to drumstick fingers , watch glass nails and gingival hypertrophy .
More precise diagnostics are carried out today with the help of echocardiography (e.g. after a heart murmur detected during a preventive check-up while listening , here a loud systolic noise over the middle of the sternum) . A cardiac catheter examination provides more accurate values and is carried out if the echo does not provide sufficient information for the operation.
A small, muscular VSD can close up spontaneously in the first few years of life.
Larger defects, which are also high near the heart valves (and thus the conduction system) or deep near the apex of the heart, or in which the defect is composed of several holes, are closed surgically, with about 26% of the defects directly through a suture can be closed and 74% with a patch (patches made of pericardium = pericardial tissue or Dacron / Goretex).
90% of VSD closures can be operated on via a "transatrial" access route. The right atrium is opened and the operation is performed through the tricuspid valve (between the right atrium and the right ventricle). A transpulmonary access route is only chosen in 1% of cases and the right ventricle is opened for the operation in approx. 9% of cases.
The operation is performed with the help of the heart-lung machine through a sternotomy (vertical opening of the sternum), which is now also possible in a minimally invasive way .
The interventional closure of a perimembranous VSD with the aid of the cardiac catheter can currently be carried out in some specialized pediatric cardiology centers in children weighing more than 8 kg. Only in the long term must it be possible to measure the results with the surgical closure. Surgical closure is currently (2005) the gold standard , especially for children weighing less than 8 kg .
After the operation, which is now usually carried out in the first year of life, the children are very healthy, develop normally and quickly catch up with any weight deficit. About a year after the operation, endocarditis prophylaxis no longer needs to be observed. Check-ups are, however, indicated at increasing intervals.
- Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition ibid 1986, ISBN 3-13-352410-0 , p. 192 f. and 196 f.
- S2k guideline for ventricular septal defects of the German Society for Pediatric Cardiology (DGPK). In: AWMF online (as of 2013)
- herzklick.de: Animated heart defect description of ventricular septal defects
- University Hospital Bonn, Department of Pediatric Cardiology: Description with graphics
- ↑ Gerd Herold : Internal Medicine 2019. Cologne 2018, ISBN 978-3-9814660-8-9 , p. 188.
- ^ Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition ibid 1986, ISBN 3-13-352410-0 , p. 196 f.
- ↑ Duden : The dictionary of medical terms. 4th edition, Georg Thieme Verlag, Stuttgart, New York 1985, ISBN 3-13-437804-3 , ISBN 3-411-02426-7 , p. 721.
- ↑ Walter Siegenthaler (Ed.): Differential diagnosis of inner diseases. 15th edition, Georg Thieme Verlag, Stuttgart / New York 1984, ISBN 3-13-344815-3 , pp. 11-19.
- ↑ Frank Henry Netter : Color Atlases of Medicine. Volume 1: Heart. Georg Thieme Verlag, Stuttgart 1976, ISBN 3-13-524001-0 , p. 46.
- ^ Günter Thiele (editor): "Handlexikon der Medizin", Urban & Schwarzenberg , Volume 4 (S – Z), Munich, Vienna, Baltimore 1980, page 2585.
- ↑ Karl Vossschulte , Hanns Gotthard Lasch , F. Heinrich (editor): "Internal Medicine and Surgery", 2nd edition, Georg Thieme Verlag , Stuttgart and New York 1981, ISBN 3-13-562602-4 , page 71.
- ^ First mentioned in Otto Dornblüth: Clinical Dictionary in the 6th edition. Verlag von Veit & Comp., Leipzig 1916, p. 296.
- ↑ Willibald Pschyrembel: Clinical Dictionary. 267th edition. De Gruyter Verlag, Berlin, Boston 2017, ISBN 978-3-11-049497-6 , p. 1899.
- ^ German pension insurance : "Social medical assessment for statutory pension insurance", 7th edition, Springer-Verlag, Berlin, Heidelberg, New York 2011, ISBN 978-3-642-10249-3 , page 306.
- ^ Hans Hamm (editor): "General medicine , family medicine ", 2nd edition, Georg Thieme Verlag , Stuttgart, New York 1986, ISBN 3-13-574802-2 , page 158.